NIH Panel Calls for Broader Access to TOL, VBAC

Recommendations Mirror Existing AAFP Policy

March 16, 2010 04:35 pm David Mitchell

An NIH consensus panel has issued recommendations for vaginal birth after cesarean delivery, or VBAC, that contain elements similar to those in recommendations made by the AAFP five years ago.

The panel said in its draft statement that trial of labor, or TOL, is a reasonable option for many women with a previous low transverse uterine incision. The panel also said that when TOL and elective repeat cesarean delivery, or ERCD, are medically equivalent options, "a shared decision-making process should be adopted and, whenever possible, the women's preference should be honored."

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

In 1980, an NIH consensus panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. Subsequently, VBAC rates increased through the 1980s and into the mid-1990s. However, rates now have dwindled to 10 percent, down from 28 percent in 1996. Conversely, cesarean rates increased from 21 percent in 1996 to 33 percent in 2007.

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.

Broadening Access

F. Gary Cunningham, M.D., chair of the consensus panel, stressed during a March 10 media briefing that the panel was issuing recommendations -- not guidelines -- but he added that the panel hopes its recommendations will broaden access to TOL.

"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.