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ACOG, VBAC and other four letter words

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Hilary Gerber

on 21 February 2011

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Transcript of ACOG, VBAC and other four letter words

ACOG, VBAC, and other
four letter words

Hilary Gerber
VBAC Summit 2011

ACOG - American College (Congress) of
Obstetricians and Gynecologists
VBAC - Vaginal Birth After Cesarean
TOLAC- Trial of Labor After Cesarean
ERC - Elective Repeat Cesarean
History of ACOG and Position statements on "Vaginal Birth Ater Previous Cesarean Delivery"
Committee Opinion #64 - October 1988
Committee Opinion #143 - October 1994
Practice Bulletin #1 - August 1995
Practice Bulletin #2 - October 1998
Practice Bulletin #5 - July 1999
Practice Bulletin #54 - July 2004
Practice Bulletin #115 - August 2010
"The American College of Obstetricians and Gynecologists is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 53,000 members, The American College of Obstetricians and Gynecologists strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care."
In their own words:
A little history
Overall cesarean rates increased from 5% in 1970 to 24.7% in 1998
VBAC rates went from 3% in 1981 and peaked in 1996 at 28.3%
McMahon (NEJM 1996) published a study linking TOLAC to significantly higher rates of perinatal death, mostly due to uterine rupture
VBAC rates begin to decline
Practice Bulletin #2 - October 1998
"Vaginal Birth After Previous Cesarean"
VBAC Rate: 27.5%, Cesarean Rate 24.7%
Created an algorithm for determining who is a good candidate for TOLAC
Some good quotes:
"With few exceptions, major improvements in newborn outcome from the increased cesarean delivery rate are yet to be proven .”
“Although there is a strong consensus that trial of labor is appropriate for most women who have had a previous low- transverse cesarean delivery, increased experience with vaginal birth after cesarean delivery (VBAC) indicates there are several potential problems.”
“Increasingly, these adverse events during trial of labor have led to malpractice suits.”
Key points:
Uterine rupture was a rare and potentially catastrophic complication
Still tying rupture to incision type only
Still had "readily available" language
Committee Opinion #64 - October 1988
Unavailable, not even an abstract
Committee Opinion #143 - October 1994
Cesarean Rate: 24%, 1/3 repeat cesareans
VBAC rate 25%
60 - 80% "successful"
Incidence of "uterine scar interruption" no greater with TOLAC (less than 1%)
Associated with type of incision (low transverse or vertical vs. classical)
Key points
"Each hospital" should have a protocol for TOLAC
Routine ERC "should be replaced" by decision process and TOLAC "should be counseled and encouraged" in appropriate candidates (one prior cesarean, lower segment incision)
NOT contraindications: two or more prior cesareans, unknown scar type, EFW over 4000 g, use of oxytocin, induction with prostaglandins, epidural
Contraindication: prior classical incision
Some quotes
"A trial of labor and delivery should occur in a hospital setting that has the professional resources to respond to acute intrapartum obstetric emergencies."
"There is no need to restrict patients to a labor bed before active labor has begun."
"A physician who is capable of evaluating labor and performing a cesarean delivery should be readily available."
Some abbreviations:
xkcd.com
Patient's choice
“Actions or policies that coerce patients to undergo either a trial of labor or a repeat cesarean procedure interfere with patient autonomy and the physician-patient relationship and undermine informed consent. The mode of delivery ultimately should be based on the specific clinical circumstances and the patient’s choice after appropriate counseling.”
Practice Bulletin #1 - August 1995
24% Cesarean Rate
1/3 Repeat Cesarean
VBAC rate 27%
Key Points:
Literature review
Gave evidence ratings to recommendations
Higher success: women with prior vaginal delivery, nonrecurring indications
Lower success (still over 2/3): cephalopelvic disproportion or failure to progress
Some quotes:
“Actions or policies that coerce patients to undergo either a trial of labor or a repeat cesarean delivery interfere with patient autonomy and the informed consent process.” Patient’s choice language removed.
“Because fetal macrosomia cannot be diagnosed accurately before birth either by palpation or ultrasonography, suspected macrosomia is not a contraindication to a trial of labor, and women should not be discouraged from a trial of labor solely on that suspicion.”
Fetal monitoring:
Once active labor has begun
At least every 15 minutes if intermittent
If continuous, evaluate strip every 15 minutes
During second stage, evaluate every 5 minutes
Availability of cesarean:
• Physician readily available throughout labor capable
of monitoring labor and performing an emergency
cesarean delivery
• Availability of anesthesia and personnel for emergency
cesarean delivery
In case of signs of uterine rupture:
"...plans for rapid diagnosis and appropriate intervention should be in place prior to undertaking a trial of labor."
Clinically adequate pelvis
No prior rupture
No other uterine scar
1 or 2 low-transverse incisions
Good candidates
Best success predictors:
For nonrecurring indication, same likelihood of vaginal delivery as someone without prior cesarean
A woman with a prior successful vaginal delivery before or after cesarean more likely to have successful TOLAC than woman without prior vaginal delivery
Least morbidity: Successful VBAC
Highest morbidity: Unsuccessful VBAC
Uterine rupture:
“Rupture of the uterine scar can be life-threatening for both mother and infant. When catastrophic uterine rupture occurs, some patients will require hysterectomy and some infants will die or will be neurologically impaired. In most cases, the cause of uterine rupture in a patient who has undergone VBAC is unknown, but poor outcomes can result even in appropriate candidates.”

Rupture linked to scar type
• Classical uterine scar (4-9%)
• T-shaped incision (4-9%)
• Low-vertical incision (1-7%)
• Low-transverse incision (0.2-1.5%)
Contraindications:
Prior classical or T-shaped incision or other transfundal uterine surgery
Contracted pelvis
Medical or obstetric complication that precludes vaginal delivery
Inability to perform IMMEDIATE emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff, or facility
Decision making process:
Language about patient autonomy and informed consent completely removed
Global mandates for TOLAC called inappropriate, but no mention of coercion for ERCD
“After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician (see Fig. 1).” (Algorithm)
Induction:
Discussion of oxytocin (Pitocin) and prostaglandin gel possibly being associated with uterine rupture. No mention of misoprostol (Cytotec). Not a contraindication.
Recommendations:
Level A –
Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.
Epidural anesthesia may be used for VBAC.
A previous uterine incision extending into the fundus is a contraindication for VBAC.
Level B –
Women with two previous low-transverse cesarean deliveries and no contraindications who wish to attempt VBAC may be allowed a trial of labor. They should be advised that the risk of uterine rupture increases as the number of cesarean deliveries increases.
Use of oxytocin or prostaglandin gel for VBAC requires close patient monitoring.
Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.
Level C –
Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians readily available to provide emergency care.
After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician.
The aftermath:
"...[R]eports of limited access to hospitals and providers willing to provide a TOL after a previous cesarean have emerged. Much of this decline in VBAC services is thought to be in response to a shift in professional and hospital guidelines indicating that “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.”

NIH Evidence Report: (2010)
Vaginal Birth After Cesarean: New Insights
Some new information:
Lydon-Rochelle et al (NEJM 2001) report a dramatically increased risk of uterine rupture with induction, especially with prostaglandins and prostaglandin analogs
(Cervadil and Cytotec)
Cesarean rate 26.1% (all time high)
VBAC rate: 12. 6%
Practice Bulletin #54 - July 2004
Some quotes:
“As a result [of well-publicized reports of uterine rupture and other complications during TOLAC], many physicians and hospitals have discontinued [VBAC] altogether. “
Safety data on the “benefits of VBAC” is based on “data from large clinical series…conducted in university or tertiary-level centers with full-time in-house obstetric and anesthesia coverage”.
“…the risk of uterine rupture during labor was nearly 5 times greater for women with 2 previous cesarean deliveries when compared with women who had 1 previous cesarean delivery. ..Therefore, for women with 2 prior cesarean deliveries, only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor.”
First mention of labor induction being associated with uterine rupture.
Awaiting spontaneous labor beyond 40 weeks gestation decreases likelihood of successful VBAC.
Induction
Predicting success:
Success rates 60 – 80%, higher for nonrecurring condition
Only 13% success rate if original cesarean occured after complete dilation
Negative assoc with success: labor augmentation, induction, maternal obesity, gestational age beyond 40 weeks, birth weight greater than 4000 g, interdelivery interval less than 19 months.
Risk / Benefit analysis:
Successful VBAC: shorter maternal hospitalization, less blood loss, fewer transfusion, fewer infection, fewer thromboembolic events
Failed TOL: Maternal: uterine rupture, hysterectomy, operative injury, increased maternal infection, need for transfusion
Neonatal: acidic pH umbilical blood gases, 5-minute Apgar scores below 7, infection
Repeat cesarean risks: placenta previa and accrete, increased risk of adv listed of successful VBAC
Risk of maternal death very low: 3 in 27,000. Perinatal death is below 1%, may be lower with repeat cesarean. Uterine rupture rates are less than 1%, numbers are inaccurate bc rupture can range from asymptomatic scar dehiscence to catastrophic rupture. Increased risk: Classical or T shaped incision, interdelivery interval of less than 24 months, single layer closure. Induction with prostaglandins and misoprostol “should be discouraged.”
Contraindications:
Previous classical or T-shaped incision or extensive transfundal uterine surgery
Previous uterine rupture
Medical or obstetrics complication that precludes vaginal delivery
Inability to perform emergency cesarean delivery because of unavailable surgeon, anesthesia, sufficient staff or facility
Two prior uterine scars and no vaginal deliveries
Recommendations:
Level A –
Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.
Epidural anesthesia may be used for VBAC.
-Removed contraindication for vertical incisions into fundus
Level B-
Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC
The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged
Removed careful supervision of induction and augmentation
Removed women with two previous low transverse incisions can be candidates
Level C –
Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians readily available to provide emergency care.
After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. *This discussion should be documented in the medical record
New: VBAC delivery is contraindicated in women with previous classical uterine incision or extensive transfundal surgery.
Where are we now?
NIH Consensus Development Conference - March 2010
NIH Evidence Report - Vaginal Delivery After Cesarean Section: New Insights
"Conclusions: Each year 1.5 million childbearing women have cesarean deliveries, and this population continues to increase. This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans."
Practice Bulletin # 115 - August 2010
Cesarean Rate: 31.1%
VBAC: 8.5%
Single leading indication for cesarean is prior cesarean (1/3)
Some quotes:
“Trial of labor after previous cesarean delivery (TOLAC) provides women who desire a vaginal delivery with the possibility of achieving that goal – a vaginal birth after cesarean delivery (VBAC).”
Mentions NIH report, saying TOLAC is a “reasonable option” and “called on organizations to facilitate access to TOLAC.”
Also that NIH panel recognized “ ‘ concerns over liability have a major impact on the willingness of physicians and healthcare institutions to offer TOL [TOLAC]’.”
Risks and benefits
Should include future pregnancies
Lower maternal and neonatal morbidity with TOLAC for good candidates
Higher maternal and neonatal morbidity for poor candidates
Who are candidates?
One previous cesarean with low transverse incision
Multiple cesareans are not contraindicated; some studies show same success rate
Twins not contraindicated
Suspected macrosomia not contraindicated
Gestation beyond 40 weeks not contraindicated
Previous low vertical incision not contraindicated
Unknown uterine scar type not contraindicated
Management of labor
Induction and augmentation remain an option
Dose dependent risk of rupture with oxytocin, and misoprostol (Cytotec) should not be used in third trimester induction
The decision making process
Potential risks and benefits of both TOLAC and ERCD should be discussed and "so that a patient can choose her intended route of delivery based on data that is most personally relevant."
Discuss early in prenatal course
Consider intended family size and uncertainty and risk of additional future cesareans
Consider resources available at intented delivery site
"...the ultimate decision...should be made by the patient in consulation with her health care provider"
The immediately available standard
The "immediately available" standard limits access to TOLAC especially in rural areas
"Restricting access was not the intention of the College's past recommendation"
No evidence that response times are responsible for large increases in safety
If resources for immediate cesarean are not availabe TOLAC should ve discussed with these factors taken into account
l
A quote:
"Health care providers and insurance carriers should do all they can to facilitate transfer of care or comanagement in support of a desired TOLAC...However, in areas with fewer deliveries and greater distances between delivery sites, organizing transfers or accessing referral centers may be untenable. Respect for patient autonomy supports the concept that patients shoud be allowed to accept increased levels of risk however patients should be clearly informed of such potential increase in risk and management alternatives... Referral also may be appropriate if, after discussion, health care providers find themselves uncomfortable with choices patients have made. Importantly, however, none of the principles, options or processes outlined here should be used by centers, health care providers or insurers to avoid appropriate effors to make TOLAC as safe as possible for those who choose this option."
Summary of recommendations:
Very similar, first Level A is still: "Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor."
Level A also says Misoprostol shoud not be used
Level B says induction may be an option otherwise
Level B says women with 2 previous cesareans may be considered candidates
Level C contains all language directly from discussion about immediate cesarean delivery and counseling including "Respect for patient autonomy supports that patients shoud be allowed to accept increased levels of risk" after appropriate informed consent
Reference List

(1) ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol 2010 August;116(2 Pt 1):450-63.
(2) McMahon MJ, Luther ER, Bowes WA, Jr., Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996 September 5;335(10):689-95.
(3) ACOG Practice Bulletin #54: vaginal birth after previous cesarean. Obstet Gynecol 2004 July;104(1):203-12.
(4) 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. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999 August;66(2):197-204.
(5) ACOG practice bulletin. Vaginal birth after previous cesarean delivery. Number 2, October 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1999 February;64(2):201-8.
(6) Roberts RG, Deutchman M, King VJ, Fryer GE, Miyoshi TJ. Changing policies on vaginal birth after cesarean: impact on access. Birth 2007 December;34(4):316-22.
(7) ACOG Committee Opinion No. 342: induction of labor for vaginal birth after cesarean delivery. Obstet Gynecol 2006 August;108(2):465-8.
(8) Plaut MM, Schwartz ML, Lubarsky SL. Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section. Am J Obstet Gynecol 1999 June;180(6 Pt 1):1535-42.
(9) Wing DA, Lovett K, Paul RH. Disruption of prior uterine incision following misoprostol for labor induction in women with previous cesarean delivery. Obstet Gynecol 1998 May;91(5 Pt 2):828-30.
(10) Guise JM, Eden K, Emeis C et al. Vaginal birth after cesarean: new insights. Evid Rep Technol Assess (Full Rep ) 2010 March;(191):1-397.
(11) Vaginal delivery after a previous cesarean birth. ACOG Committee opinion. Number 143-October 1994 (replaces No. 64, October 1988). Committee on Obstetric Practice. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1995 January;48(1):127-9.
(12) Vaginal delivery after previous cesarean birth. Number 1--August 1995. Committee on Practice Patterns. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1996 January;52(1):90-8.
(13) Lydon-Rochelle M, Holt VL, Easterling TR, Martin DP. Risk of uterine rupture during labor among women with a prior cesarean delivery. N Engl J Med 2001 July 5;345(1):3-8.
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