Wednesday, March 10, 2010

Vaginal Births After Cesareans: New Insights

The NIH summit on VBAC safety comes to a close today. A report has been issued and low and behold.....

VBACs are ok and the cesarean rates need to drop. I'm dumbfounded at this shocking noise. Do you detect a touch of sarcasm there?

It's absolutely wonderful that this topic has been brought to the attention of the public and media. But to those of us in the know - doesn't really seem to be anything new or shocking. Here's a copied excerpt from the abstract summary...

Results: We identified 3,134 citations and reviewed 963 papers for inclusion, of which 203 papers met inclusion and were quality rated. Studies of maternal and infant outcomes reported data based upon actual rather than intended router of delivery. The range for TOL and VBAC rates was large (28-82 percent and 49-87 percent, respectively) with the highest rates being reported in studies outside of the U.S. Predictors of women having a TOL were having a prior vaginal delivery and settings of higher-level care (e.g., tertiary care centers). TOL rates in U.S. studies declined in studies initiated after 1996 from 63 to 47 percent, but the VBAC rate remained unimproved. Hispanic and African American women were less likely than their white counterparts to have a vaginal delivery. Overall rates of maternal harms were low for both TOL and ERCD.

While rare for both TOL and ERCD, maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 300 per 1,000 and the risk was significantly increased with TOL (47/1,000 versus 3/1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. No models have been able to accurately predict women who are more likely to deliver by VBAC or to rupture.

Women with a prior cesarean delivery had a statistically significant increased risk of placenta previa compared with women with no prior cesarean, at a rate of 12 per 1,000 and risk increasing with the number of cesareans. Compared with previa patients without a prior cesarean delivery, women with one prior cesarean and previa had a statistically significant increased risk of blood transfusion (15 versus 32.2 percent), hysterectomy (0.7 to 4 percent versus 10 percent), and composite maternal morbidity (15 versus 23-30 percent). Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD. Insufficient data were found on nonmedical factors such as medical liability, economics, hospital staffing, structure and setting, which all appear to be important drivers for VBAC.

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. Relatively unexamined contextual factors such as medical liability, economics, hospital structure, and staffing may need to be addressed to prioritize VBAC services. There is still no evidence to inform patients, clinicians, or policymakers about the outcomes of intended route of delivery because the evidence is based largely on the actual route of delivery. This inception cohort is the equivalent of intention to treat for randomized controlled trials and this gap in information is critical. A list of future research considerations as prioritized by national experts is also highlighted in this report.

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