Decreasing cesareans: VBAC and patient empowerment

COMMITTEE ON PRACTICE BULLETINS-OBSTETRICS Practice Bulletin #184: Vaginal Birth After Cesarean Delivery. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:(5):e217-e233. Full text of Practice Bulletin #184 is available to ACOG members at https://www.acog.org/Resources-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Cesarean

VAGINAL BIRTH AFTER CESAREAN DELIVERY Trial of labor after cesarean delivery (TOLAC) refers to a planned attempt to deliver vaginally by a woman who has had a previous cesarean delivery, regardless of the outcome. This method provides women who desire a vaginal delivery the possibility of achieving that goal-a vaginal birth after cesarean delivery (VBAC). In addition to fulfilling a patient’s preference for vaginal delivery, at an individual level, VBAC is associated with decreased maternal morbidity and a decreased risk of complications in future pregnancies as well as a decrease in the overall cesarean delivery rate at the population level (1–3). However, although TOLAC is appropriate for many women, several factors increase the likelihood of a failed trial of labor, which in turn is associated with increased maternal and perinatal morbidity when compared with a successful trial of labor (ie, VBAC) and elective repeat cesarean delivery (4–6). Therefore, assessing the likelihood of VBAC as well as the individual risks is important when determining who is an appropriate candidate for TOLAC. Thus, the purpose of this document is to review the risks and benefits of TOLAC in various clinical situations and to provide practical guidelines for counseling and management of patients who will attempt to give birth vaginally after a previous cesarean delivery.

Commentary: Decreasing cesareans: VBAC and patient empowerment

The American College of Obstetricians and Gynecologists’ (ACOG) newly updated guidance¹ providing greater support for women in labor who want to attempt vaginal delivery after a delivery by cesarean section is very good news, signaling a more patient-focused approach for childbirth. Both ACOG and the Society for Maternal-Fetal Medicine made clear in a 2014 Obstetric Care Consensus that culture change was necessary to lower our nation’s cesarean delivery rates.²

An estimated one-third of American babies are now delivered by cesarean,³ up from 5% in 1970,⁴ despite the fact that a surgical birth can add risk to a mother and her child. Women who undergo the procedure may experience hemorrhage, infection, thromboemboli, a longer recovery, and the possibility of a life-threatening condition (placenta accreta) in subsequent pregnancies. Studies indicate that many factors can affect cesarean delivery rates including: where you live (up to 35% variation by census data),⁵ your hospital (7.1 - 69%),⁶ even your nurse (8.3 - 48%).⁷ These data point to the fact that everyone on the care team needs to focus on providing best practices and evidence-based decision-making.

Worse, even though a cesarean delivery does not preclude future vaginal delivery-what’s known as vaginal birth after cesarean delivery, or VBAC-attempts at VBAC have declined dramatically over the last few decades.⁸ The VBAC attempt rate is only about 9%,⁹ even though the overall success rate for women who attempt a trial of labor after cesarean delivery is estimated at 60% to 80%.¹ We can do better. 

One reason the revised ACOG guidelines are good news is that they call on Labor & Delivery units, staff and hospitals to be fully prepared to help women whose VBAC attempts are not successful, noting that “Level I facilities must have the ability to begin emergency cesarean delivery within a time interval that best considers maternal and fetal risks and benefits with the provision of emergency care.” Essentially: “hope for the best, but prepare for the worst,” which is always a prudent roadmap in medicine and obstetrics.

The updated guidelines also include a powerful sentence: “Coercion is not acceptable.” Many women report feeling “pressured” to ditch their VBAC plans before medical circumstances dictate the need for cesarean-and research shows that only about 3% of cesareans are attributable to “maternal request.”¹⁰

The strong language employed by ACOG regarding “coercion” makes it clear that obstetricians-and the labor and delivery teams providing care, and hospitals in which they practice-should dig deeper into their reserves of patience during their patients’ labor. To do that, our medical system must be more generally attuned to the voice of the empowered patient. An informed dialogue is the focus of the Joint Commission’s SpeakUp™ campaign, including the “ABCs of Cesareans” effort. Patience mandates that progression of labor is determined by fetal and maternal status, and in concert with patient engagement. If both mom and fetus have reassuring parameters, then vaginal birth should be attempted, avoiding preconceived determinations of an “appropriate time frame for delivery.” 

In addition, many hospitals are pursuing transparency initiatives, such as internal sharing of clinicians’ cesarean rates, to encourage ob/gyns to examine their clinical approaches. Others have implemented ob/gyn hospitalist programs, thus enabling clinicians to respond quickly to obstetric emergencies, optimize patient safety and quality care, and afford women time to labor on their own schedule, even when delivering by VBAC. A 2015 study of a California community hospital found that providing access to midwives and implementing an ob/gyn hospitalist program was associated with a 7% drop in the primary cesarean delivery rate in the first year, and a decrease of 1.7% per year thereafter, while the VBAC rate increased from 13.3% to 22.4%.¹¹

By reframing VBAC as a more viable option, the new ACOG guidelines make it clear that women must be afforded the opportunity to make choices about delivery in consultation with their doctors. This shared medical decision-making model allows patients to have a voice and physicians to share best evidence-based practices. Increasing the number of VBAC attempts can help to lower our nation’s cesarean delivery rate. These new guidelines, along with appropriate patient and facility selection, will hopefully result in increased VBAC. In obstetrics, more than any other specialty, patience goes hand-in-hand with patients.

Disclosure The author reports no potential conflicts of interest with regard to this article.

ACOG references

1. Little MO, Lyerly AD, Mitchell LM, Armstrong EM, Harris LH, Kukla R, et al. Mode of delivery: toward responsible inclusion of patient preferences. Obstet Gynecol 2008;112:913–8. (Level III)

2. Menacker F, Curtin SC. Trends in cesarean birth and vaginal birth after previous cesarean, 1991–99. Natl Vital Stat Rep 2001;49:1–16.

3. Curtin SC, Gregory KD, Korst LM, Uddin SF. Maternal morbidity for vaginal and cesarean deliveries, according to previous cesarean history: new data from the birth certificate, 2013. Natl Vital Stat Rep. 2015;64(4):1–13.

4. Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity. Am J Obstet Gynecol 2001;184:1365,71; discussion 1371–3. 

5. Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. National Institute of Child Health and Human Development Maternal–Fetal Medicine Units Network. N Engl J Med 2004;351:2581–9.

6. Macones GA, Peipert J, Nelson DB, Odibo A, Stevens EJ, Stamilio DM, et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol 2005;193:1656–62.

Commentary references

1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 2017;130:(5):e217-e233. 

2. American College of Obstetricians and Gynecologists (College); Society for Maternal-Fetal Medicine, Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe Prevention of the Primary Cesarean Delivery. Am J Obstet Gynecol. 2014 Mar; 210(3):179-93. 

3. Martin JA, Hamilton BE, Osterman JK, Driscoll AK, Matthews TJ, Division of Vital Statistics. Natl Vital Stat Rep. January 2017. Volume 66, Number 1, pages 1-70. 

4. Placek PJ, Taffel SM. Trends in cesarean section rates for the United States, 1970-78. Public Health Rep. 1980;95(6):540-548. 

5. Cesarean Birth Trends: Where You Live Significantly Impacts How You Give Birth. Blue Cross Blue Shield, The Health of America Report. August 2016.

6. Kozhimannil KB, Law MR, Virnig BA. Cesarean Delivery Rates Vary 10-Fold Among US Hospitals; Reducing Variation May Address Quality, Cost Issues. Health Affairs. 2013;32(3)527-535. 

7. Edmonds JK, O’Hara M, Clarke SP, Shah NT. Variation in Cesarean Birth Rates by Labor and Delivery Nurses. J Obstet Gynecol Neonatal Nurs. July 2017, volume 46, Issue 4, page 486-493. 

8. Grobman WA, Lai Y, Landon MB, et al. The change in the VBAC Rate: An Epidemiologic Analysis. Paediatr Perinat Epidemiol. 2011;25(1):37-43. 

9. Menacker F, Declercq E, Macdorman MF. Cesarean delivery: background, trends, and epidemiology. Semin Perinatol. 2006 Oct; 30(5):235-41. 

10. NIH State-of-the-Science Conference Statement on cesarean delivery on maternal request. NIH Consens State Sci Statements. 2006 Mar 27-29;23(1):1–29. 

11. Rosenstein M, Nijagal M, Nakagawa S, Gregorich S, Kupperman M. The effect of expanded midwifery and hospitalist services on primary cesarean delivery rates. Am J Obstet Gynecol. 2015;212(1):S5-S6.