Vaginal birth after cesarean: new insights on maternal and neonatal outcomes.
ABSTRACT To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC).
Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts.
Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses.
We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery).
Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.
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ABSTRACT: BACKGROUND: In 2010, the NIH and ACOG recommended increasing women's access to trial of labor after cesarean (TOLAC). This study explored access to TOLAC in California, change in access since 2007 and 2010, and characteristics of TOLAC and non-TOLAC hospitals. METHODS: Between November 2011 and June 2012, charge nurses at all civilian California birth hospitals were surveyed about hospitals' TOLAC availability and requirements for providers. VBAC rates were obtained from the California Office of Statewide Health Planning and Development (OSHPD). Distance between hospitals was calculated using OSHPD geocoding. RESULTS: All 243 birth hospitals that were contacted participated. In 2010, among the 56% TOLAC hospitals, the median VBAC rate among TOLAC hospitals was 10.8% (range 0-37.3%). The most cited reason for low VBAC rates was physician unwillingness to perform them, especially due to the requirement to be continually present during labor. TOLAC hospitals were more likely to be larger hospitals in urban communities with obstetrical residency training. However, there were six (11.3%) residency programs in non-TOLAC hospitals and 5 (13.5%) rural hospitals offering TOLAC. The majority of TOLAC hospitals had 24/7 anesthesia coverage and required the obstetrician to be continually present if a TOLAC patient was admitted; 17 (12.2%) allowed personnel to be 15-30 minutes away. TOLAC eligibility criteria included one prior cesarean (32.4%), spontaneous labor (52.5%), continuous fetal monitoring and intravenous access (99.3%), and epidural analgesia (19.4%). The mean distance from a non-TOLAC to a TOLAC hospital was 37 mi. with 25% of non-TOLAC hospitals more than 51 mi. from the closest TOLAC hospital.In 2012, 139 hospitals (57.2%) offered TOLAC, 16.6% fewer than in 2007. Since 2010, five hospitals started and four stopped offering TOLAC, a net gain of one hospital offering TOLAC with three more considering it. Only two hospitals cited change in ACOG guidelines as a reason for the change. CONCLUSIONS: Despite the 2010 NIH and ACOG recommendations encouraging greater access to TOLAC, 44% of California hospitals do not allow TOLAC. Of the 56% allowing TOLAC, 10.8% report fewer than 3% VBAC births. Thus, national recommendations encouraging greater access to TOLAC had a minor effect in California.BMC Pregnancy and Childbirth 04/2013; 13(1):83. · 2.52 Impact Factor
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ABSTRACT: Pregnant women who had a previous cesarean birth must choose whether to have a repeat cesarean or to attempt a vaginal birth. Many of these women are candidates for a trial of labor. Current practice guidelines recommend that women should be thoroughly counseled during prenatal care about the benefits and harms of both a trial of labor after cesarean (TOLAC) and an elective repeat cesarean delivery and be offered the opportunity to make an informed decision about mode of birth in collaboration with their provider. The purpose of this article is to improve the process of counseling, decision making, and informed consent by increasing health care providers' knowledge about the essential elements of shared decision making. Factors that affect the decisions to be made and concepts that are critical for effective counseling are explored, including clinical considerations, women's perspectives, decision-making models, health literacy and numeracy, communicating risk, and the use of decision aids. Issues related to birth sites for TOLAC are also discussed, including access, safety, refusal of surgery, and clinical management.Journal of midwifery & women's health 04/2014; · 1.13 Impact Factor
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ABSTRACT: The purpose of this study was to determine the impact of increasing numbers of cesarean deliveries on maternal morbidity. This study was performed for the 2010 National Institutes of Health Consensus Development Conference on Vaginal Birth After Cesarean: New Insights. We conducted a systematic review and metaanalysis of observational studies. Twenty-one studies (2,282,922 deliveries) were included. The rate of hysterectomy, blood transfusions, adhesions, and surgical injury all increased with increasing number of cesarean deliveries. The incidence of placenta previa increased from 10/1000 deliveries with 1 previous cesarean delivery to 28/1000 with ≥3 cesarean deliveries. Compared with women with previa and no previous cesarean delivery, women with previa and ≥3 cesarean deliveries had a statistically significant increased risk of accreta (3.3-4% vs 50-67%), hysterectomy (0.7-4% vs 50-67%), and composite maternal morbidity (15% vs 83%; odds ratio, 33.6; 95% confidence interval, 14.6-77.4). Serious maternal morbidity progressively increased as the number of previous cesarean deliveries increased.American journal of obstetrics and gynecology 09/2011; 205(3):262.e1-8. · 3.28 Impact Factor