Archive for March, 2010

The NIH VBAC Consensus Conference: Will It Pave the Road to Hell with Good Intentions?

March 6th, 2010 by avatar

First the good news: based on the presenters, it looks like the NIH VBAC conference will be a great improvement over the elective cesarean surgery travesty of four years ago. The conference seems likely to provide solid, evidence-based information on for whom and under what circumstances VBAC is safest and most likely to end in vaginal birth. Objective, unbiased information on these points is sorely needed, as illustrated by this 2008 response by ACOG vice president Dr. Ralph Hale, who one would expect to know better, to a plea to make VBAC more available:

VBAC is potentially an extremely dangerous procedure for both mother and infant. Although 98% of women can potentially have a successful VBAC, in two percent of cases the result can be a rupture of the old scar. If this happens, then death of the baby is almost certain and death of the mother is probable. Even if the mother does not die, virtually 100% will lose their child bearing ability. To prevent these disasters, the ability to perform immediate surgery is critical.

In point of fact, with appropriate care the scar rupture rate can be 0.5% or less (6,13,15), not 2%, and the chance of the baby dying as a result of scar rupture is 5% (9), not “almost certain.” As for the mother, women rarely die or have hysterectomies, but both are more common with elective repeat cesarean than planned VBAC (3,17,18,19).

Before we break out the champagne, though, consider this: nowhere in the program is any acknowledgement of a patient’s fundamental right to refuse surgery. Quite the opposite. The background statement is rife with the language of doctors giving (or withholding) permission:

For most of the 20th century, once a woman had undergone a cesarean . . ., many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, in 1980 a National Institutes of Health Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered.

Even more telling, VBAC is positioned as a patient and provider “preference.” The background section uses this term as does the title of the session on obstetric decision making, and Anne Lyerly, the obstetrician speaker on VBAC ethics, is co-author of the commentary “Mode of delivery: toward responsible inclusion of patient preferences.”

The problem with patient preference is that it is readily trumped by provider preference. If VBAC is no more than a menu option, the danger in determining who makes a good candidate and what constitutes optimal circumstances for VBAC is that it legitimizes its opposite: doctors and institutions denying VBAC to women they don’t think make the cut or where they don’t think safety for VBAC is adequate. (The latter, BTW, is spurious. Emergencies occur in non VBAC labors. If a hospital isn’t safe for a VBAC labor, then it isn’t safe for any woman to labor there. Not to mention that ACOG guidelines for labor induction and American Society of Anesthesiologist guidelines for epidurals require the ability to perform an urgent cesarean because of the potential for just such emergencies, but no one is setting strictures on these procedures [1,2].)

A secondary danger of the “preference” perspective is that conference presenters may treat non-clinical factors such as “medico-legal concerns” and “economic considerations” as valid reasons for VBAC refusal instead of obstacles that must be overcome. This would leave us where we are now with obstetricians and hospitals free to do as they choose, and what they choose is no VBACs. A 2005 survey found that more than half the women wanting a VBAC were denied that option, a 2009 survey of 2850 hospitals revealed that half of them had a ban or de facto ban against VBAC, and Lord knows we do not need any more stories like Joy Szabo’s.

To give the conference planners and presenters their due, normally, it makes perfect sense to limit procedures to those with the skill to perform them and require their performance in environments with adequate resources. It makes sense as well as to allow providers and institutions to decline performing them. But VBAC is the exception because it is not a procedure. Labor is what inevitably happens at the end of pregnancy. Refusing VBAC means forcing women to agree to major surgery they neither want nor need in order to obtain medical care.

Depriving a woman of choice on grounds of the baby’s safety, the primary clinical rationale for VBAC denial, values the child over the mother. This is not hyperbole. According to studies of a large U.S. population, the maternal risk of death (3 per 10,000) with elective repeat cesarean is in the same ballpark with the risk of the baby dying subsequent to scar rupture during a VBAC labor (1 per 10,000) (13,19). Moreover, as the conference will discuss, a woman undergoing repeat cesarean not only runs the risks of that surgery, but an increasing risk of placental attachment abnormalities in any future pregnancies as she accumulates surgeries, abnormalities that threaten both her life and that of the fetus. By contrast, once a woman has a VBAC, she will almost always continue to have uneventful VBACs in future pregnancies. VBAC denial is the sole instance where doctors feel justified in compelling one person to undergo a medical procedure to benefit another party, but no ethical principle or law allows this, including when the beneficiary will otherwise surely die, which is far from the case with VBAC.

Failure to recognize that VBAC is a right has another consequence as well. If you start from this premise, it follows that a key question will be how best to promote safe vaginal birth in women desiring VBAC, but this is missing from the agenda. My researches for the VBAC chapter of the new edition of Obstetric Myths turned up much food for thought on this issue. For example, a study on the large U.S. population mentioned above reported scar rupture rates of 9 per 1000 with labor augmentation and 10 per 1000 with induction but only 4 per 1000 in women laboring spontaneously (13). If every woman had labored without stimulation, 63 women would have had scar ruptures instead of 124. On the other hand, a study reported equally low scar rupture rates in induced labors (3 per 1000) as in labors with spontaneous onset (16), which suggests that while spontaneous labor is optimal, women who truly require induction can be induced without excess risk provided clinicians pay proper attention to patient selection and induction protocol. Research also shows that physiologic care substantially increases VBAC rate and reduces scar rupture rate (15). The birth center VBAC study reported a VBAC rate of 81% in women with no prior vaginal birth, 9 to 20 more women per 100 than among similar women in nine studies (4,5,7,8,10-12,14,20) who had conventional obstetric management. The scar rupture rate overall was a mere 2 per 1000.

We rightly should applaud any effort that helps women and clinicians decide between planned VBAC or repeat cesarean but lament any attempt to curtail a woman’s right to refuse surgery, be it on clinical or nonclinical grounds. VBAC is a right, not a preference, a right, let me add, not abrogated by the clinician’s opinion of its wisdom. It does not matter if you, me, and everyone on the planet were to line up and say to a woman VBAC is a bad idea in your case, she still has the right to say “no” to surgery. Clinicians and institutions must be brought to accept their ethical and professional obligation to provide best practice care to every woman wanting planned VBAC. If the conference fails in this task, then whatever it accomplishes, it will fall short of its duty to childbearing women with previous cesareans.

1. ACOG. Induction of labor. ACOG Practice Bulletin No 107 2009.

2. ASA. Guidelines for regional anesthesia in obstetrics. 2007. (Accessed 2/12/2010, at http://www.asahq.org/publicationsAndServices/standards/45.pdf.)

3. Blanchette H, Blanchette M, McCabe J, et al. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol 2001;184(7):1478-84; discussion 84-7.

4. Cahill AG, Stamilio DM, Odibo AO, et al. Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol 2006;195(4):1143-7.

5. Caughey AB, Shipp TD, Repke JT, et al. Trial of labor after cesarean delivery: the effect of previous vaginal delivery. Am J Obstet Gynecol 1998;179(4):938-41.

6. Chauhan SP, Martin JN, Jr., Henrichs CE, et al. Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature. Am J Obstet Gynecol 2003;189(2):408-17.

7. Gonen R, Barak S, Nissenblat V, et al. The outcome and cumulative morbidity associated with the second and third postcesarean delivery. Am J Perinatol 2007;24(8):483-6.

8. Goodall PT, Ahn JT, Chapa JB, et al. Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery. Am J Obstet Gynecol 2005;192(5):1423-6.

9. Guise JM, McDonagh M, Hashima JN, et al. Vaginal birth after cesarean (VBAC) Report/Technology Assessment No. 71. Rockville, MD: Agency for Healthcare Research and Quality; 2003 March 2003. Report No.: AHRQ Publication No. 03-E018.

10. Gyamfi C, Juhasz G, Gyamfi P, et al. Increased success of trial of labor after previous vaginal birth after cesarean. Obstet Gynecol 2004;104(4):715-9.

11. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol 2004;104(2):273-7.

12. Kwee A, Bots ML, Visser GH, et al. Obstetric management and outcome of pregnancy in women with a history of caesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2007;132(2):171-6.

13. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004;351(25):2581-9.

14. Landon MB, Leindecker S, Spong CY, et al. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005;193(3 Pt 2):1016-23.

15. Lieberman E, Ernst EK, Rooks JP, et al. Results of the national study of vaginal birth after cesarean in birth centers. Obstet Gynecol 2004;104(5 Pt 1):933-42.

16. Locatelli A, Regalia AL, Ghidini A, et al. Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section. BJOG 2004;111(12):1394-9.

17. Loebel G, Zelop CM, Egan JF, et al. Maternal and neonatal morbidity after elective repeat Cesarean delivery versus a trial of labor after previous Cesarean delivery in a community teaching hospital. J Matern Fetal Neonatal Med 2004;15(4):243-6.

18. McMahon MJ, Luther ER, Bowes WA, Jr., et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996;335(10):689-95.

19. Spong CY, Landon MB, Gilbert S, et al. Risk of uterine rupture and adverse perinatal outcome at term after cesarean delivery. Obstet Gynecol 2007;110(4):801-7.

20. Turner MJ, Agnew G, Langan H. Uterine rupture and labour after a previous low transverse caesarean section. BJOG 2006;113(6):729-32.

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Some thoughts on practice guidelines and VBAC as a “vital option”

March 3rd, 2010 by avatar

VBACNext week, scientists, policy experts, and advocates will come together for the National Institutes of Health Consensus Development Conference on Vaginal Birth after Cesarean (VBAC). A panel will spend three days reviewing the evidence and hearing public testimony. On Wednesday they’ll announce their findings in a press telebriefing.

The NIH isn’t calling their findings “practice guidelines,” but they’re very likely to be taken as such. I’ll admit: the concept of guidelines, at least as they are developed and used in the United States, is a little troubling to me. On the one hand, guidelines can represent, as the Institute of Medicine suggests, “a move away from unexamined reliance on professional judgment toward more structured support and accountability for such judgment.” But what about their limitations?

Guidelines are seen by the public and by health professionals as objective and scientific, but:

Experts often look at the same body of evidence and come up with different conclusions.

  • Chauhan and colleagues have demonstrated significant variation across national guidelines in management of shoulder dystocia and intrauterine growth restriction. In other words, the American Congress of Obstetricians and Gynecologists (ACOG) doesn’t agree with its counterparts in other countries about how these conditions should be diagnosed and treated.
  • A study in the current issue of Birth compared VBAC guidelines from six countries and found little agreement not just on practice and management issues, but on the data itself: they found a four-fold variation in the reported upper-end risk of uterine rupture, as well as significant variation in the reported likelihood of vaginal birth in a VBAC labor.
  • In 2008, ACOG reversed its position on the safety of expectant management of prelabor rupture of membranes, without citing any new evidence at all (and despite the publication of new evidence that, if anything, strengthens the argument for expectant management.)

Often, experts aren’t even looking at the same body of evidence.

  • In the comparative study of national VBAC guidelines, 22 individual references were cited for uterine rupture, none of which appeared in all six guidelines. Only two studies were cited in three of the national guidelines and an additional 5 studies were cited in two national guidelines.
  • In the shoulder dystocia review only half of eligible references were cited in both of the national guidelines the researchers analyzed.
  • In the review of intrauterine growth restriction, only 12% of references were cited in both national guidelines.
  • Guideline authors rarely if ever include a rationale for why they included the studies they included and excluded others.

The evidence they are looking at is often limited or flawed.

Even when guidelines are evidence-based, they’re often ignored.

  • When ACOG issued new guidelines about fetal heart rate monitoring in labor last year, blogs and Twitter went nuts with the news that they had finally admitted that intermittent auscultation is safe and effective, and that continuous electronic fetal monitoring doesn’t live up to its many promises.  I pointed out at Our Bodies, Our Blog that ACOG hadn’t changed a single word of its guidelines with respect to intermittent auscultation and the limitations of EFM; it’s just that their recommendations had been ignored. (No surprise: they’re still being ignored.)

And then there’s the not-so-small issue that guidelines suggest that a “one size fits all” approach will translate into the best care for everyone, which anyone who takes care of patients or has been a patient recognizes is flat-out false. We all have different reasons for making the health choices we do. An individual’s informed consent or refusal can and should trump guidelines, but in practice, guidelines dictate practice and policy for all women. Case in point: the last time ACOG issued VBAC guidelines, hospitals and care providers began banning vaginal birth outright in women with prior cesarean surgery. The VBAC rate in this country plummeted virtually overnight.

The International Cesarean Awareness Network is hosting a blog carnival on the theme, “Why is VBAC a Vital Option?” I suspect we’re going to hear a huge range of responses, along with some stories of the astounding lengths some women have gone to in order to ensure that VBAC remained a viable option for them. Not every woman goes to these lengths – plenty of women are perfectly happy to have repeat cesareans and would make that choice even if VBAC was offered and supported – but these stories underscore the fact that blanket guidelines will not apply to every woman everywhere.

Despite all of this, I’m actually rather optimistic about the NIH VBAC Conference. In my mind, the situation around VBAC has gotten so bad in this country that a fresh look at the issues and the evidence can only help matters. Plus, the meeting comes on the heels of major recommendations for maternity care reform and the conference findings are likely to echo and lend credence to many of these. Judith Rooks shares six more reasons we should be optimistic about the upcoming meeting. And last but not least, there is a huge consumer contingent planning to have their voices heard at this conference either in person or by webcast, and many of them are connected via social networks to a far greater number of consumers. You can hear me and Lamaze President-Elect Debra Bingham on The Feminist Breeder’s Blog Talk Radio Show on Monday, recapping Day One of the proceedings.

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