Vaginal Birth After Cesarean: New Insights

NIH Consensus Development Conference on
Vaginal Birth After Cesarean:
New Insights

March 8–10, 2010
Bethesda, Maryland

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Background

Vaginal birth after cesarean (VBAC) is the delivery of a baby through the vagina after a previous cesarean delivery. For most of the 20th century, once a woman had undergone a cesarean (the delivery of a baby through an incision made in the abdominal wall and uterus), many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, in 1980 a National Institutes of Health (NIH) Consensus Development Conference panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to try to labor and deliver vaginally rather than plan a cesarean delivery was thus offered and exercised more often from the 1980s through the early 1990s. Since 1996, however, VBAC rates in the United States have consistently declined, while cesarean delivery rates have been steadily rising.

The exact causes of these shifts are not entirely understood. A frequently cited concern about VBAC is the possibility of uterine rupture during labor, because a cesarean delivery leaves a scar in the wall of the uterus at the incision site, which is weaker than other uterine tissue. Attempted VBAC may also be associated with endometritis (infection of the lining of the uterus), the need for a hysterectomy (removal of the uterus) or blood transfusion, as well as neurologic injury to the baby. However, repeat cesarean delivery may also carry a risk of bleeding or hysterectomy, uterine infections, and respiratory problems for the newborn. Having multiple cesarean deliveries may also be associated with placental problems in future pregnancies. Other important considerations that may influence decision making include the number of previous cesarean deliveries a woman has experienced, the surgical incision used during previous cesarean delivery, the reason for the previous surgical delivery, her age, how far the pregnancy is along relative to her due date, and the size and position of her baby. Given the complexity of this issue, a thorough examination of the relative balance of benefits and harms to mother and baby will be of immediate utility to practitioners and pregnant mothers in deciding upon a planned mode of delivery.

A number of non-clinical factors are involved in this decision as well, and may be influencing the decline in VBAC rates. Some individual practitioners and hospitals in the U.S. have decreased or eliminated their use of VBAC. Professional society guidelines may influence utilization rates because some medical centers do not offer the recommended supporting services for a trial of labor after cesarean (e.g., immediate availability of a surgeon who can perform a cesarean delivery and on-site anesthesiologists). Information related to complications of an unsuccessful attempt at VBAC, medico-legal concerns, personal preferences of patients and clinicians, and insurance policies and economic considerations may all play a role in changing practice patterns. Improved understanding of the clinical risks and benefits, and how they interact with legal, ethical, and economic forces to shape provider and patient choices about VBAC may have important implications for health services planning.

To advance understanding of these important issues, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Medical Applications of Research of the NIH will convene a Consensus Development Conference from March 8–10, 2010. The conference will address the following key questions:

What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
What are the short- and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms?
What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?
Invited experts will present information pertinent to the posed questions and a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ) will be summarized. Conference attendees will have ample time to ask questions and provide comments during open discussion periods. After weighing the scientific evidence, an unbiased, independent panel will prepare and present a consensus statement addressing the key conference questions.

Sponsors


Eunice Kennedy Shriver National Institute of Child Health and Human Development
Office of Medical Applications of Research
of the National Institutes of Health

Co-sponsor


National Institute of Nursing Research
Office of Research on Women's Health

The Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention provided additional conference development support.

Agenda

Monday, March 8, 2010

8:30 a.m. Introduction and Opening Remarks
TBA
Eunice Kennedy Shriver National Institute
of Child Health and Human Development
National Institutes of Health
8:40 a.m. Charge to the Panel
Jennifer M. Croswell, M.D., M.P.H.
Acting Director
Office of Medical Applications of Research
Office of the Director
National Institutes of Health
8:50 a.m. Conference Overview and Panel Activities
F. Gary Cunningham, M.D.
Panel and Conference Chairperson
Beatrice and Miguel Elias Distinguished
Chair in Obstetrics and Gynecology
Professor, Obstetrics and Gynecology
University of Texas Southwestern Medical
Center at Dallas
9:00 a.m. Overview of the Topic
Caroline Signore, M.D., M.P.H.
Medical Officer
Pregnancy and Perinatology Branch
Center for Developmental Biology and
Perinatal Medicine
Eunice Kennedy Shriver National Institute
of Child Health and Human Development

I. What Are the Rates and Patterns of Utilization of Trial of Labor After Prior Cesarean, Vaginal Birth After Cesarean, and Repeat Cesarean Delivery in the United States?
9:15 a.m. Trends and Patterns of VBAC Availability in the United States
Kimberly D. Gregory, M.D., M.P.H.
Vice Chair, Womens Healthcare Quality and Performance Improvement
Department of Obstetrics and Gynecology
Cedars Sinai Medical Center

II. Among Women Who Attempt a Trial of Labor After Prior Cesarean, What Is the Vaginal Delivery Rate and the Factors That Influence It?
9:35 a.m. Evidence-based Practice Center Presentation I: Trial of Labor, Vaginal Delivery Rates, and Relevant Factors
9:55 a.m. Success Rates and Predicting Successful VBAC
William A. Grobman, M.D., M.B.A.
Associate Professor
Division of Maternal Fetal Medicine
Department of Obstetrics and Gynecology
Feinberg School of Medicine
Northwestern University
10:15 a.m. Discussion

III. What Are the Short- and Long-Term Benefits and Harms to the Mother of Attempting Trial of Labor After Prior Cesarean Versus Elective Repeat Cesarean Delivery, and What Factors Influence Benefits and Harms?

10:45 a.m. Evidence-based Practice Center Presentation II:
Maternal Benefits and Harms, and Relevant Factors

11:05 a.m. Delivery After Previous Cesarean: Short Term Maternal Outcomes
Mona T. Lydon-Rochelle, Ph.D., M.P.H., C.N.M.
Associate Professor/Perinatal Epidemiologist
National Perinatal Epidemiology Centre
Anu Research Centre
Department of Obstetrics and Gynaecology and
Department of Epidemiology & Public Health
University College Cork
11:25 a.m. Discussion
11:45 a.m. Lunch

Panel Executive Session
12:45 p.m. Delivery After Previous Cesarean: Long Term Maternal Outcomes
Robert M. Silver, M.D.
Professor
Chief, Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
University of Utah Health Sciences Center
1:05 p.m. Predicting Uterine Rupture
Mark B. Landon, M.D.
Professor
Director, Division of Maternal Fetal Medicine
Department of Obstetrics and Gynecology
Ohio State University College of Medicine
1:25 p.m. Discussion

IV. What Are the Short- and Long-Term Benefits and Harms to the Baby of Maternal Attempt at Trial of Labor After Prior Cesarean Versus Elective Repeat Cesarean Delivery, and What Factors Influence Benefits and Harms?

1:45 p.m. Evidence-based Practice Center Presentation III:
Infant Benefits and Harms, and Relevant Factors

2:05 p.m. Delivery After Previous Cesarean: Short Term Infant Outcomes
Lucky Jain, M.D., M.B.A.
Richard W. Blumberg Professor and Executive Vice Chairman
Department of Pediatrics
Emory University School of Medicine

2:25 p.m. Delivery After Previous Cesarean: Long Term Infant Outcomes
T. Michael OShea, M.D., M.P.H.
Professor
Chief, Division of Neonatology
Department of Pediatrics
Baptist Medical Center
Wake Forest University

2:45 p.m. Synthesis: Weighing Risks to Mother and Infant
George A. Macones, M.D., M.S.C.E.
Elaine and Mitchell Yanow Professor and Chairman
Department of Obstetrics and Gynecology
Washington University School of Medicine
3:05 p.m. Discussion

V. What Are the Non-Medical Factors That Influence the Patterns and Utilization of Trial of Labor After Prior Cesarean?

3:45 p.m. Trial of Labor versus Elective Repeat Cesarean: An Administrator's
Perspective
Michael L. Socol, M.D.
Thomas J. Watkins Memorial Professor and Vice Chair
Department of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine
Feinberg School of Medicine
Northwestern University

4:15 p.m. Evaluating Professional Society Guidelines on VBAC
Emmanuel Bujold, M.D., F.R.C.S.C.
Department of Obstetrics and Gynaecology
Faculté de Médecine
Université Laval
4:35 p.m. Discussion
5:00 p.m. Adjournment


Tuesday, March 9, 2010

V. What Are the Non-Medical Factors That Influence the Patterns And Utilization of Trial of Labor After Prior Cesarean? (Continued)
8:30 a.m. Trial of Labor versus Elective Repeat Cesarean: The Impact of
Anesthesiologist Availability
David J. Birnbach, M.D., M.P.H.
Professor
Department of Anesthesiology and Obstetrics and Gynecology
Associate Dean and Director, Jackson Memorial Hospital Center for Patient Safety
Miller School of Medicine
University of Miami

8:50 a.m. Exploring the Immediately Available Physician Standard
Howard Minkoff, M.D.
Professor
Department of Obstetrics and Gynecology
SUNY-Brooklyn; Maimonides Medical Center

9:10 a.m. Understanding Risk, Patient and Provider Preferences, and Obstetric
Decision Making
Miriam Kuppermann, Ph.D., M.P.H.
Professor of Obstetrics, Gynecology & Epidemiology
University of California, San Francisco

9:30 a.m. Discussion

10:00a.m. The Medical Ethics of VBAC
Anne D. Lyerly, M.D.
Associate Professor
Department of Obstetrics and Gynecology
Faculty Associate, Center for the Study of Medical Ethics and Humanities
Duke University

10:20 a.m. Mothers' Stories
Rita Rubin
Medical Reporter
USA Today

10:40 a.m. Walking the Line: The Obstetric Provider Experience
Chet Edward Wells, M.D.
Professor
Department of Obstetrics and Gynecology
University of Texas Southwestern Medical Center at Dallas
11:00 a.m. Discussion
11:30 a.m. Adjournment


Wednesday, March 10, 2010

9:00 a.m. Presentation of the Draft Consensus Statement
9:30 a.m. Public Discussion
11:00 a.m. Adjournment
Panel Meets in Executive Session
2:00 p.m. Press Telebriefing

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