Reassess VBAC guidelines, expert panel advises

Hospitals, providers, insurers, consumers, and policymakers should work together to develop integrated services to lower barriers for women attempting to have a vaginal birth after a cesarean delivery (VBAC) with a low transverse uterine incision, a 15-member expert panel recommended last month at the National Institutes of Health (NIH) Consensus Development Conference on Vaginal Birth After Cesarean in Bethesda, Maryland.

Although NIH convened the consensus conference committee, its findings do not constitute an official statement. The committee specifically urged the American Congress of Obstetricians and Gynecologists and the American Society of Anesthesiologists to reassess their guidelines that call for trial of labor (TOL) services to be allowed only when there is immediate availability of capabilities, including obstetric anesthesia and a physician capable of performing an emergency delivery. Surveys have found that 30% of hospitals have stopped providing TOL because they cannot provide immediate surgical and anesthesia services.

The committee, which spent months reviewing thousands of pages of studies and spent 2 days hearing presentations, pointed out that, overall, cesarean deliveries have increased in the United States from 21% in 1996 to 33% in 2007, with both the repeat cesarean rate and the primary cesarean delivery rate increasing. Surveys show that one-third of hospitals and one-half of physicians no longer offer TOL for women who have had a cesarean, and about 92% of women also have cesareans for their next delivery.

The report also notes that in women with a prior transverse uterine incision, both TOL and elective repeat cesarean delivery carry important risks and benefits, and those differ for the woman and for her fetus. That poses profound ethical dilemmas, made worse by the lack of high-level evidence about medical and nonmedical factors, the report states.

Much of the report is an outline of what is not known. The authors write that factors that affect the course of labor and its clinical management are incompletely understood, as are long-term maternal and perinatal biologic and psychosocial outcomes after VBAC and the effects that VBAC, unsuccessful TOL, and elective repeat cesarean delivery have on breastfeeding.

Factors including geography, professional association guidelines, provider type, liability concerns, workforce availability and training, health insurance, and institutional policies appear to affect access to TOL, but they also have not been well studied, the report indicates.

The draft statement, the complete evidence report, and an archived Webcast of the conference may be found at http://consensus.nih.gov/2010/vbac.htm.