VBAC Statement 2010

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NIH Consensus Development Conference Statement on

Vaginal Birth After Cesarean: New Insights

NIH Consensus and State-of-the-Science Statements

Volume 27, Number 3

March 810, 2010

NATIONAL INSTITUTES OF HEALTHOice o the Director


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About the NIH Consensus Development Program

National Institutes o Health (NIH) Consensus and State-o-the-Science Statements are prepared by independent panels o health

proessionals and public representatives on the basis o (1) the resultso a systematic literature review prepared under contract with theAgency or Healthcare Research and Quality (AHRQ), (2) presentationsby investigators working in areas relevant to the conerence questionsduring a 2-day public session, (3) questions and statements romconerence attendees during open discussion periods that are part othe public session, and (4) closed deliberations by the panel duringthe remainder o the second day and the morning o the third. Thisstatement is an independent report o the panel and is not a policystatement o the NIH or the Federal Government.

The statement reects the panels assessment o medical knowledgeavailable at the time the statement was written. Thus, it provides asnapshot in time o the state o knowledge on the conerence topic.When reading the statement, keep in mind that new knowledge isinevitably accumulating through medical research, and that the inormationprovided is not a substitute or proessional medical care or advice.

Reerence Inormation

Individuals who wish to cite this statement should use theollowing ormat:

Cunningham FG, Bangdiwala S, Brown SS, Dean TM, Frederiksen M, Rowland Hogue CJ, King T, Spencer Lukacz E, McCullough LB,Nicholson W, Petit N, Probstfeld JL, Viguera AC, Wong CA, ZimmetSC. National Institutes o Health Consensus Development ConerenceStatement: Vaginal Birth Ater Cesarean: New Insights. March 810,2010. Obstetrics & Gynecology. 2010; 115(6):12791295.

Publications Ordering Information

NIH Consensus Statements, State-o-the-Science Statements, andrelated materials are available by visiting http://consensus.nih.gov; bycalling toll ree 8886442667; or by emailing [email protected] requests can be mailed to the NIH Consensus DevelopmentProgram Inormation Center, P.O. Box 2577, Kensington, MD 20891.When ordering copies o this statement, please reerence item number

2010-00122-STMT.

The evidence report prepared or this conerence through AHRQ isavailable on the web via http://www.ahrq.gov/clinic/tp/vbacuptp.htm.Printed copies may be ordered rom the AHRQ PublicationsClearinghouse by calling 8003589295. Requesters should askor AHRQ Publication No. 10-E003.
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NIH Consensus Development Conference Statement on

Vaginal Birth After Cesarean: New Insights

NIH Consensus and State-of-the-Science Statements

Volume 27, Number 3

March 810, 2010

NATIONAL INSTITUTES OF HEALTHOice o the Director


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Disclosure Statement

All o the panelists who participated in this conerence

and contributed to the writing o this statement were

identifed as having no fnancial or scientifc conict o

interest, and all signed orms attesting to this act. Unlike

the expert speakers who present scientifc data at the

conerence, the individuals invited to participate on NIH

Consensus and State-o-the-Science Panels are reviewed

prior to selection to ensure that they are not proponents

o an advocacy position with regard to the topic and are

not identifed with research that could be used to answer

the conerence questions.

For more inormation about conerence procedures,

please see http://consensus.nih.gov/aboutcdp.htm.

Archived Conference Webcast

The NIH Consensus Development Conerence on

Vaginal Birth Ater Cesarean: New Insights waswebcast live March 810, 2010. The webcast is

archived and available or viewing ree o charge at

http://consensus.nih.gov/2010/vbac.htm.
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Abstract

Objective

To provide healthcare providers, patients, and the

general public with a responsible assessment o currently

available data on vaginal birth ater cesarean (VBAC).

Participants

A non-Department o Health and Human Services,

nonadvocate 15-member panel representing the

felds o obstetrics and gynecology, urogynecology,

maternal and etal medicine, pediatrics, midwiery,

clinical pharmacology, medical ethics, internal medicine,

amily medicine, perinatal and reproductive psychiatry,

anesthesiology, nursing, biostatistics, epidemiology,

healthcare regulation, risk management, and a public

representative. In addition, 20 experts rom pertinent felds

presented data to the panel and conerence audience.

Evidence

Presentations by experts and a systematic review o

the literature prepared by the Oregon Evidence-based

Practice Center, through the Agency or Healthcare

Research and Quality (AHRQ). Scientifc evidence was

given precedence over anecdotal experience.

Conference Process

The panel drated its statement based on scientifc

evidence presented in open orum and on published

scientifc literature. The drat statement was presented

on the fnal day o the conerence and circulated to the

audience or comment. The panel released a revised

statement later that day at http://consensus.nih.gov. Thisstatement is an independent report o the panel and is

not a policy statement o the National Institutes o Health

(NIH) or the Federal Government.

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Conclusions

Given the available evidence, trial o labor is a reasonable

option or many pregnant women with one prior low

transverse uterine incision. The data reviewed in this

report show that both trial o labor and elective repeat

cesarean delivery or a pregnant woman with one prior

transverse uterine incision have important risks and

benefts and that these risks and benefts dier or the

woman and her etus. This poses a proound ethical

dilemma or the woman, as well as her caregivers,

because beneft or the woman may come at the price

o increased risk or the etus and vice versa. This

conundrum is worsened by the general paucity o high-

level evidence about both medical and nonmedical

actors, which prevents the precise quantifcation o

risks and benefts that might help to make an inormed

decision about trial o labor compared with elective

repeat cesarean delivery. The panel was mindul o these

clinical and ethical uncertainties in making the ollowingconclusions and recommendations.

One o the panels major goals is to support pregnant

women with one prior transverse uterine incision to make

inormed decisions about trial o labor compared with

elective repeat cesarean delivery. The panel recommends

that clinicians and other maternity care providers use

the responses to the six questions, especially questions

3 and 4, to incorporate an evidence-based approachinto the decisionmaking process. Inormation, including

risk assessment, should be shared with the woman at

a level and pace that she can understand. When trial o

labor and elective repeat cesarean delivery are medically

equivalent options, a shared decisionmaking process

should be adopted and, whenever possible, the womans

preerence should be honored.

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The panel is concerned about the barriers that women

ace in gaining access to clinicians and acilities that

are able and willing to oer trial o labor. Given the low

level o evidence or the requirement or immediatelyavailable surgical and anesthesia personnel in current

guidelines, the panel recommends that the American

College o Obstetricians and Gynecologists and the

American Society o Anesthesiologists reassess this

requirement with specifc reerence to other obstetric

complications o comparable risk, risk stratifcation,

and in light o limited physician and nursing resources.

Healthcare organizations, physicians, and otherclinicians should consider making public their trial o

labor policies and VBAC rates, as well as their plans

or responding to obstetric emergencies. The panel

recommends that hospitals, maternity care providers,

healthcare and proessional liability insurers, consumers,

and policymakers collaborate on the development o

integrated services that could mitigate or even eliminate

current barriers to trial o labor.

The panel is concerned that medical-legal considerations

add to, and in many instances exacerbate, these

barriers to trial o labor. Policymakers, providers, and

other stakeholders must collaborate in developing and

implementing appropriate strategies to mitigate the

chilling eect the medical-legal environment has on

access to care.High-quality research is needed in many areas. The panel

has identifed areas that need attention in response to

question 6. Research in these areas should be given

appropriate priority and should be adequately unded

especially studies that would help to characterize more

precisely the short-term and long-term maternal, etal,

and neonatal outcomes o trial o labor and elective repeat

cesarean delivery.

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Introduction

Vaginal birth ater cesarean (VBAC) describes vaginal

delivery by a woman who has had a previous cesarean

delivery. For most o the 20th century, once a woman

had undergone a cesarean delivery, clinicians believed

that her uture pregnancies required cesarean delivery.

Studies rom the 1960s suggested that this practice may

not always be necessary. In 1980, a National Institutes

o Health (NIH) Consensus Development Conerence

Panel questioned the necessity o routine repeat cesarean

deliveries and outlined situations in which VBAC couldbe considered. The option or a woman with a previous

cesarean delivery to have a trial o labor was oered and

exercised more oten in the 1980s through 1996. Since

1996, however, the number o VBACs has declined,

contributing to the overall increase in cesarean delivery

(Figure 1). Although we recognize that primary cesarean

deliveries are the driving orce behind the total cesarean

delivery rates, the ocus o this report is on trial o laborandrepeatcesarean deliveries.

Figure 1. Rates of Total Cesarean Deliveries, Primary

Cesarean Deliveries, and VBAC, 19892007

VBAC

1989

0

5

10

15

20

25

30

35

1991 1993 1995 1997 1999 2001 2003 2005 2007

Total cesarean delivery

Primary cesarean delivery

Year

Rateper100livebirths

Data rom the National Center or Health Statistics.

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A number o medical and nonmedical actors have

contributed to this decline in the VBAC rate since the

mid-1990s, although many o these actors are not well

understood. A signifcant medical actor that is requentlycited as a reason to avoid trial o labor is concern about

the possibility o uterine rupturebecause an unsuccessul

trial o labor, in which a woman undergoes a repeat

cesarean delivery instead o a vaginal delivery, has a

a higher rate o complications compared to VBAC or

elective repeat cesarean delivery. Nonmedical actors

include, among other things, restrictions on access to a

trial o labor and the eect o the current medical-legalclimate on relevant practice patterns. To advance

understanding o these important issues, the Eunice

Kennedy ShriverNational Institute o Child Health and

Human Development and the Ofce o Medical Applications

o Research o NIH convened a Consensus Development

Conerence on March 810, 2010. The conerence was

grounded in the view that a thorough evaluation o the

relevant research would help pregnant women and theirmaternity care providers when making decisions about

the mode o delivery ater a previous cesarean delivery.

Improved understanding o the clinical risks and benefts

and how they interact with nonmedical actors also may

have important implications or inormed decisionmaking

and health services planning.

The ollowing key questions were addressed by theConsensus Development Conerence:

1. What are the rates and patterns o utilization o trial

o labor ater prior cesarean delivery, vaginal birth

ater cesarean delivery, and repeat cesarean delivery

in the United States?

2. Among women who attempt a trial o labor ater

prior cesarean delivery, what is the vaginal deliveryrate and the actors that inuence it?

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3. What are the short- and long-term benefts and harms

to the mother o attempting trial o labor ater prior

cesarean versus elective repeat cesarean delivery,

and what actors inuence benefts and harms?4. What are the short- and long-term benefts and

harms to the baby o maternal attempt at trial o

labor ater prior cesarean versus elective repeat

cesarean delivery, and what actors inuence

benefts and harms?

5. What are the nonmedical actors that inuence the

patterns and utilization o trial o labor ater priorcesarean delivery?

6. What are the critical gaps in the evidence

or decisionmaking, and what are the priority

investigations needed to address these gaps?

Invited experts presented inormation pertinent to the

posed questions and a systematic literature review

prepared under contract with AHRQ, available athttp://www.ahrq.gov/clinic/tp/vbacuptp.htm, was

summarized. Conerence attendees asked questions

and provided comments. Ater weighing the scientifc

evidence, an unbiased, independent panel prepared

this consensus statement.

Pregnant women, clinicians, and investigators use

terms in conicting and conusing ways. For consistencythroughout this document, the ollowing defnitions

are provided:

Trial o labor: A planned attempt to labor by a womanwho has had a previous cesarean delivery, also known

as trial o labor ater cesarean.

Vaginal birth ater cesarean delivery (VBAC): Vaginaldelivery ater a trial o labor; that is, a successul trialo labor.

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1. What Are the Rates and Patterns oUtilization o Trial o Labor Ater PriorCesarean, Vaginal Birth Ater Cesarean,and Repeat Cesarean Delivery in theUnited States?

The overall cesarean delivery rate is the sum o primary and

repeat cesarean deliveries per 100 live births. Following

a decline between 1990 and 1996, cesarean delivery

rates in the United States rose markedly rom 21 percent

in 1996 to 32 percent in 2007 (see Figure 1). Both the

primary and repeat cesarean birth rates have risen. Among

women with a prior cesarean delivery, VBAC rates vary

by racial/ethnic status, medical condition, region o the

country, type and location o hospital, and may vary by

type o provider. For Medicaid patients, VBAC rates

are higher or women enrolled in health maintenance

organizations or who deliver at public (not private) hospitals.

Various surveys have revealed that since 1996, approximately

one-third o hospitals and one-hal o physicians no

longer oer trial o labor. A survey o American College

o Obstetricians and Gynecologists Fellows showed that,

between 2003 and 2006, 26 percent stopped oering

a trial o labor or women with a history o cesarean

deliveries regardless o prior vaginal delivery experience.

A woman is at low risk or pregnancy complications i

she has completed 37 weeks o gestation with one etuswhose head is in the vertex position in the womb and has

no obstetric or medical complications. Among low-risk

women, the repeat cesarean delivery rate had increased

to 89 percent by 2003. Since 2003, U.S. Standard Birth

Certifcates have included inormation on VBAC and

trial o labor. Among the 19 states that had adopted

the standard certifcate, approximately 92 percent o

all women who had a previous cesarean had a repeatcesarean or their next delivery in 2006. A sharp rise in

repeat cesareans was observed at all maternal ages

and or all racial/ethnic groups.

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Given these trends, VBAC is an important issue to explore.

Although the number o women and their maternity care

providers aced with the question o whether to attempt

trial o labor has markedly increased, there has been aconcurrent, dramatic drop in VBAC. Yet cesarean and

VBAC rates are identifed as quality indicators or maternal

health by policymakers, insurance providers, and healthcare

quality monitoring groups. Success o trial o labor is

consistently high, ranging rom 60 to 80 percent, whereas

the risk o uterine rupture is low, at less than 1 percent.

Regardless, one reason given or reduced VBAC is

concern about uterine rupture during trial o labor.

Little is known about population-based rates and patterns

o utilization o trial o labor ater previous cesarean

deliveries. A potential source o inormation about this issue

is the Pregnancy Risk Assessment Monitoring System

(PRAMS), an ongoing surveillance program conducted by

the Centers or Disease Control and Prevention and state

health departments. PRAMS is a population-based survey

o a sample o women who have recently delivered. Each

year, a relatively small sample o postpartum women is

selected in each state (n=1,300 to n=3,400). In addition

to a core questionnaire, participating states may choose

to supplement rom a set o standard questions or derive

questions o their own.

New Jersey represents a good example o the use o

birth data. New Jersey tracked trial o labor and repeatcesareans rom 1997 to 2008 using electronic birth systems.

Over this time period, there has been an increase in repeat

cesarean deliveries rom less than 50 percent to nearly

85 percent. There was very little dierence in this rate

between women with or without private insurance or by

maternal risk status. Between 2003 and 2005, 79 percent

o low-risk women in New Jersey underwent repeat

cesarean delivery without a trial o labor. Since 2009,New Jersey has been utilizing PRAMS to learn more

about mothers and providers predelivery intentions

or VBAC and inormed consent or type o delivery.

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In summary, in states where data are collected, VBAC

has dropped dramatically since 1996. Although the

data among racial/ethnic groups vary, repeat cesarean

deliveries without trial o labor have increased in all thesegroups. Rates o repeat cesarean continue to increase

even among women who are low risk.

2. Among Women Who Attempt a Trial oLabor Ater Prior Cesarean, What Is the

Vaginal Delivery Rate and the FactorsThat Inuence It?

Although the trial o labor rate has declined dramatically over

the past several decades, the vaginal delivery rate ater trial

o labor has remained constant at approximately 74 percent.

The reported rates are highly variable, the overall strength

o the body o evidence is moderate, and most studies

use data rom large tertiary care and training centers.In addition, many studies are observational and do not

adequately address issues o selection bias. Conounding

and inadequate measurement o variables are a concern.

Taken together, these methodological and statistical

issues limit the strength o the inormation available.

Many demographic and obstetric actors are associated

with the likelihood o VBAC. Race and ethnicity are the

strongest demographic predictors o vaginal delivery ater

trial o labor. Hispanic and Arican American women have

lower rates o VBAC than non-Hispanic white women.

Increasing maternal age, single marital status, and less

than 12 years o education also have been associated

with lower rates o VBAC. Women who deliver at rural and

private hospitals and the presence o maternal disease

(e.g., hypertension, diabetes, asthma, seizures, renal

disease, thyroid disease, heart disease) may also be

associated with a decreased likelihood o VBAC. Greater

maternal height and body mass index below 30 kg/m2

are associated with an increased likelihood o VBAC.

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A prior history o vaginal delivery, either beore or ater a

prior cesarean delivery, is consistently associated with

an increased likelihood o VBAC. For example, in one

retrospective cohort study, the vaginal birth rate ater trialo labor was 63 percent in women with no prior vaginal

delivery, 83 percent in women with a prior vaginal delivery

beore cesarean delivery, and 94 percent in women with

a prior VBAC. The rate o VBAC increases with each prior

VBAC. Nonrecurring indications or cesarean delivery are

also associated with a higher rate o VBAC. For example,

compared to arrest o labor, prior cesarean delivery or

malpresentation is associated with a higher rate o VBAC.Women who previously delivered babies weighing less

than 4,000 grams are more likely to have a VBAC than are

those who delivered heavier babies.

Current pregnancy actors also are associated with vaginal

delivery ater trial o labor, including labor characteristics

and inant actors. Gestational age greater than 40 weeks,

labor augmentation, and labor induction are associated

with a decreased rate o VBAC. The most consistent inant

actor associated with an increased likelihood o VBAC is

birth weight less than 4,000 grams. Lower gestational age

at delivery is associated with increased VBAC rates when

compared to term gestational age at delivery. Labor actors

associated with a higher VBAC rate include greater cervical

dilation at admission or at rupture o membranes. The

likelihood o VBAC increases i cervical eacementreaches 75 to 90 percent. Vertex position, etal head

engagement or a lower station, and higher Bishop score

(a scoring system used to estimate the success o induction

o labor) also increase the likelihood o VBAC. Data

regarding epidural analgesia and VBAC are inconsistent.

A major area o interest is whether antepartum or

intrapartum management strategiesor example, methods

o labor inductioninuence the rate o VBAC. The overallestimated rate o vaginal birth ater any method o labor

induction is 63 percent. Studies demonstrate that the

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rate o VBAC ranges rom 54 percent or induction o

labor with mechanical (transcervical balloon catheter) to

69 percent or induction with pharmacologic methods.

The majority o studies were conducted in large, tertiarycare settings, and many studies were conducted outside

the United States. Results were not stratifed by age,

race, ethnicity, or baseline risk. Rigorous studies have not

compared VBAC rates with dierent induction methods.

Several screening tools have been proposed or

predicting VBAC. These tools take into account actors

such as maternal age, body mass index, prior vaginal

delivery, prior cesarean indication, cervical dilation, and

eacement at admission. The models have reasonable

ability to predict the likelihood o a successul trial o labor

at the population level but are not accurate in predicting

the risk o a uterine rupture or unsuccessul trial o labor.

Studies have not verifed the utility o these screening

tools or predicting outcomes or individual women.

3. What Are the Short- and Long-TermBenefts and Harms to the Mother oAttempting Trial o Labor Ater PriorCesarean Versus Elective RepeatCesarean Delivery, and What Factors

Inuence Benefts and Harms?Overall, pregnancy and birth have inherent risks and

benefts. There is controversy regarding the risks and

benefts o cesarean delivery, and little high-quality

evidence is available about benefts and harms o trial o

labor and elective repeat cesarean delivery specifcally.

A previous NIH State-o-the-Science Conerence

(http://consensus.nih.gov/2006/cesarean.htm) partiallyaddressed the global issues related to benefts and

harms o cesarean compared to vaginal delivery, which

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is out o the scope o this review. Ideally, or the purposes

o counseling women with a prior cesarean delivery about

their options or mode o delivery, data rom women

who gave birth at term should be used. Unortunately,insufcient data are available about women at term only;

thus, this review includes data on outcomes related to

trial o labor compared with elective repeat cesarean

delivery or all women who give birth at all gestational

ages. When data are available or term gestations only,

these data are presented separately.

Limitations to these fndings include diering defnitions

or the outcomes, heterogeneity among studies, and

variation in study designs. Mortality and morbidity o trial

o labor and elective repeat cesarean delivery are likely to

be underestimated due to reporting bias and the potential

or missing complications that occur ater discharge. The

major outcomes reecting benefts and harms o trial o

labor are presented in bold ont and in descending order

o grade o evidence within this section. However, the

actors inuencing these outcomes do not always hold

the same level o evidence, which is highlighted in each

section below.

For women with a prior cesarean delivery, there are

three possible outcomes: a VBAC (i.e., a successul

trial o labor), an unsuccessul trial o labor resulting in

cesarean delivery, or an elective repeat cesarean delivery.

In general, the overallbenefts o trial o labor are directlyrelated to having a VBAC, because these women typically

have the lowest morbidity. Similarly, theharms o trial o

labor are associated with an unsuccessul trial o labor

resulting in cesarean delivery, because these deliveries

have the highest morbidity. Although there is merit in

studying each o these three groups separately, the

data comparing trial o labor to elective repeat cesarean

delivery that were reviewed or this conerence typicallycombined VBAC and unsuccessul trial o labor ending

in cesarean delivery. Consequently, the health outcomes

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reported below or women who have an unsuccessul

trial o labor and subsequently undergo repeat cesarean

delivery are counted in the overall trial o labor cohort(s).

This approach best reects the knowledge that isavailable to women who have had a previous cesarean

delivery at the time they are deciding on the subsequent

mode o delivery or a current pregnancy.

SHORT-TERM BENEFITS FOR TRIAL OF LABOR

High Grade o Evidence

Maternal mortality is low, but it may be increasing in

the United States. Women who have a trial o labor,

regardless o ultimate mode o delivery, are at decreased

risk o maternal mortality compared to elective repeat

cesarean delivery. Although there is some heterogeneity

among studies reporting death in term only compared to

any gestational age, overall estimates o maternal death

number 3.8 per 100,000 or women who undergo a trialo labor compared with 13.4 per 100,000 live births or

elective repeat cesarean delivery (Table 1). At term, these

numbers decrease to 1.9 (trial o labor) compared with

9.6 (elective repeat cesarean delivery) maternal deaths

per 100,000 live births. Studies o actors aecting

maternal mortality with trial o labor and elective repeat

cesarean delivery are o low-grade evidence; however,

they imply lower mortality or trial o labor in high-volumehospitals (more than 500 deliveries per year). Table 1

puts into perspective the death rates o mothers in the

population o women with prior cesarean, relative to other

common causes o death in the general population.

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Table 1. Mortality Rates

Overall

Trial of Labor

Prior CesareanDelivery

Elective Repeat

Cesarean Prior

CesareanDelivery

All-cause mortality in women

by age (per 100,000 total

U.S. population)*

1524 years 42

2534 years 64

3544 years 136Motor vehicle-related

mortality (per 100,000 total

U.S. population)(Men and

women, 2544 years)*

16

Maternal mortality

(pregnancy to delivery,

all ages, per 100,000 live

births)*

13

Maternal mortality in womenwith prior cesarean, all ages,

at delivery, per 100,000 live

births

4 13

* U.S. 2007 National Center or Health Statistics data.

Data rom supporting systematic evidence review.

Moderate Grade o Evidence

The overall risk ohysterectomy is statistically similar ortrial o labor compared with elective repeat cesarean delivery

(157 versus 280 per 100,000, respectively) and may be

less in women at term. Limited evidence suggests that the

risk o hysterectomy increases with induction o labor,

high-risk pregnancy, and increasing number o cesarean

deliveries (420 or one prior cesarean delivery, 900 or

two prior cesarean deliveries, 2,410 or three prior cesarean

deliveries, 3,490 or our prior cesarean deliveries, and8,990 or fve or more prior cesarean deliveries per 100,000).

The risk oblood transusion is not signifcantly dierent

or trial o labor or elective repeat cesarean delivery

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(900 versus 1,200 per 100,000, respectively). Factors that

increase this risk include induction o labor with no prior

vaginal delivery, high-risk pregnancy, and an increased

number o prior cesarean deliveries.

Low Grade o Evidence

There is shorter hospitalization overall or trial o labor

compared to elective repeat cesarean delivery. This

beneft does not pertain to morbidly obese women.

A single study suggests lower rates odeep venous

thrombosis (DVT) in women undergoing trial o labor

compared with elective repeat cesarean delivery

(40 versus 100 per 100,000, respectively).

Insufcient Evidence or Short-Term Beneft

A womans perceptions o her birth experience, initial

parent-inant interactions, and ability to perorm activities o

daily living or initiate breasteeding may dier by mode o

delivery. There are insufcient comparative studies in women

with a prior cesarean delivery to address these issues.

SHORT-TERM HARMS FOR TRIAL OF LABOR


None


Uterine rupture is defned as an anatomic separation o

the uterine muscle with or without symptoms. Although

uncommon, this event can be catastrophic and remains

the most dreaded short-term complication o trial o labor.

The concern or uterine rupture is an important actor

aecting counseling regarding risks and benefts o trialo labor. There is a clear increased risk o uterine rupture

in women who have a trial o labor compared to elective

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repeat cesarean delivery. The presence o a uterine

rupture has numerous adverse consequences or both

mother and baby.

Incidence of Uterine Rupture

Considering all gestational ages, uterine rupture occurs

in approximately 325 per 100,000 women undergoing

trial o labor. The risk o uterine rupture or women who

undergo trial o labor at term is 778 per 100,000. The risk

o uterine rupture or women who undergo elective repeat

cesarean delivery is 26 per 100,000 when all gestational

ages are evaluated and 22 per 100,000 or women who

are at term at the time they give birth. Unortunately,

there is no reliable way to predict who will have a uterine

rupture.

Factors That Increase the Risk of Uterine Rupture

The ollowing discussion o actors that aect the risk o

uterine rupture is based on low-grade evidence.

Women with classical and low vertical uterine scars

have an increased risk o rupture when compared to

women who had a low transverse uterine incision at the

time o cesarean delivery. Induction o laborhas been

associated with uterine rupture. However, due to variation

among studies with respect to indications or delivery,

induction protocol, agent and dose, and subsequentuse o oxytocin, it is difcult to identiy an absolute risk

o uterine rupture associated with induction. The risk o

rupture in women at term who have their labor induced

is higher (1,500 per 100,000) than the risk o rupture i

labor starts spontaneously (800 per 100,000). The risk

o rupture may be increased in women who are induced

at more than 40 weeks (3,200 per 100,000 at more than

40 weeks versus 1,500 per 100,000 at 37 to 40 weeks).There does not appear to be an increased risk o rupture

with oxytocin augmentation o spontaneous labor.

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A recently published meta-analysis revealed that an

increase in the number o prior cesarean deliveries

may increase the risks o uterine rupture; two or more

previous cesarean deliveries were associated with higherrupture rates (1,590 per 100,000) than one prior cesarean

delivery (560 per 100,000). Other actors that may

increase the risk o uterine rupture include unavorable

cervical status at the time o admission, obesity, inter-

pregnancy interval o 18 months or less, single-layer

closure or the initial cesarean delivery, an inant weighing

more than 4,000 grams, and giving birth in a low-volume

hospital. Insufcient data are available to quantiy thespecifc eects o these actors.

Factors That Decrease the Risk of Uterine Rupture

Aprior vaginal birth (beore or ater the previous

cesarean delivery) decreases the risk o uterine rupture

to approximately 600 per 100,000.

Consequences of Uterine Rupture

There have been no reported maternal deaths due to

uterine rupture. Overall, 14 to 33 percent o women

will need a hysterectomy when the uterus ruptures.

Approximately 6 percent o uterine ruptures will result in

perinatal death. This is an overall risk o intrapartum etal

death o 20 per 100,000 women undergoing trial o labor.

For term pregnancies, the reported risk o etal death with

uterine rupture is less than 3 percent. Although the risk is

similarly low, there is insufcient evidence to quantiy the

neonatal morbidity directly related to uterine rupture.

Insufcient Evidence or Short-Term Harm

Reported rates oinection vary widely depending on

the defnitions used. Overall, the rates o inection arelow (below 3 percent or less than 3,000 per 100,000)

with increased trends toward higher inection rates with

trial o labor. Morbid obesity, unsuccessul trial o labor,

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and increased number o cesarean deliveries increase

inection rates. Evidence is sparse or rates o short-term

surgical injury. There do not appear to be dierences

between trial o labor and elective repeat cesarean delivery,but surgical injury increases with unsuccessul trial o labor,

vertical abdominal incision (as opposed to Pannenstiel

incision), and increasing number o cesarean deliveries.

LONG-TERM BENEFITS OF TRIAL OF LABOR


None


There is an association between cesarean delivery and

abnormal placental position and growth in subsequent

pregnancies and the risk o having abnormal placental

position and growth increases with increasing number o

cesarean deliveries. Although most women in the United

States have two or ewer births, the chance o having

abnormal placental position or growth in subsequent

pregnancy are o great concern or the 28 percent o

women who have more than two births. An important

aspect in counseling women about trial o labor compared

with elective repeat cesarean delivery should thereore

include the womans plans or uture ertility.For the purposes o comparing outcomes between

trial o labor and elective repeat cesarean delivery, it is

recognized that all these women have had at least one

cesarean delivery, and are at baseline higher risk or

abnormal placental position and growth compared to

women who have not had a cesarean delivery. Overall, the

major beneft o trial o labor is the 74 percent likelihood

o VBAC and avoidance o multiple cesarean deliveries.However, women who have an unsuccessul trial o labor

and repeat cesarean delivery do not realize the beneft

o decreased risk or abnormal placental position or

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growth in subsequent pregnancies. The ollowing health

outcomes occur less requently in women who have a

VBAC (i.e., a successul trial o labor) and are o most

concern or women who have more than two births.The incidence oplacenta previa (placenta covering the

cervix) signifcantly increases in women with each additional

cesarean delivery, occurring in 900 per 100,000 women

who have one prior cesarean delivery, 1,700 per 100,000

women who have two prior cesarean deliveries, and

3,000 per 100,000 in women who have three or more

cesarean deliveries. As the number o cesarean deliveries

increase, major morbidity, including placenta accreta

and hysterectomy, also increase when a pleacenta

previa is present.

Even in the absence o placenta previa, the incidence

oplacenta accreta, increta, and percreta (growth

o the placenta into or through the uterine muscle)

increases with the number o cesarean deliveries. This

has a proound eect on the womans uture reproductivecapability. The baseline risk o placenta accreta in a

woman with one prior cesarean delivery is 319 per

100,000; this increases to 570 per 100,000 or two

prior cesarean deliveries, and approximately 2,400 per

100,000 or three or more cesarean deliveries. No actors

have been identifed to decrease this risk. There does

not appear to be an increased incidence oplacental

abruption (i.e., premature separation o the normallyimplanted placenta rom the uterus) with increasing

number o cesarean deliveries, although the risk is

increased when women who have one prior cesarean

delivery are compared to women who have not had a

cesarean delivery.


None

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Insufcient Evidence or Long-Term Beneft

Although cesarean delivery has been implicated in other

conditions such as chronic pain, ectopic pregnancy, stillbirth,

and inertility, there are no studies examining these conditions

in women with prior cesarean delivery with respect to trial

o labor compared with elective repeat cesarean delivery.

With respect to complications related to subsequent

surgery, no studies have specifcally compared trial o

labor with elective repeat cesarean delivery. However, it is

generally recognized that an increasing number o abdominal

surgeries is associated with the ollowing complications:

clinically signifcant adhesions, perioperative complications

at time o subsequent repeat cesarean delivery, bowel

and ureteral injuries, and perioperative complications at

time o non-pregnancy-related hysterectomy.

LONG-TERM HARMS OF TRIAL OF LABOR

High or Moderate Grades o EvidenceNone


None

Insufcient Evidence or Long-Term Harm

No studies on long-term pelvic foor unction have

compared women who have a trial o labor with women

who have an elective repeat cesarean delivery. Although

women who experience a vaginal delivery may have

increased risks o pelvic oor disorders, such as stress

incontinence or pelvic organ prolapse, compared to

women who have a cesarean delivery, the labor progress

and timing o the original cesarean delivery inuence theserisks. As such, elective repeat cesarean delivery or the

prevention o pelvic oor disorders should not be considered

protective against stress incontinence and prolapse.

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4. What Are the Short- and Long-TermBenefts and Harms to the Baby oMaternal Attempt at Trial o Labor AterPrior Cesarean Versus Elective RepeatCesarean Delivery, and What FactorsInuence Benefts and Harms?

The discussion between women and their maternity care

providers about whether to proceed with elective repeat

cesarean delivery or trial o labor ollowing prior cesarean

delivery must assess potential benefts and harms or bothmother and etus. In contrast to the data on maternal

outcomes, there is little or no evidence on short- or long-

term neonatal outcomes ater trial o labor compared to

elective repeat cesarean delivery. Much o the evidence is

o low quality, characterized by inconsistencies in outcomes

across studies and dierences in outcome defnitions, and

variations in study design. However, there are extensive

data documenting dierences in neonatal outcomesollowing vaginal delivery compared to cesarean delivery in

general. Overall, ollowing cesarean delivery, inants have

increased rates o short-term respiratory sequelae, intererence

with initial mother-inant contact, and delayed breasteeding

initiation compared to inants born vaginally. Long-term

consequences may include asthma. However, there are

little data on these outcomes when trial o labor and

elective repeat cesarean delivery are compared in womenwho had a prior cesarean delivery. Furthermore, there are

essentially no data on actors contributing to neonatal

benefts and harms. The major outcomes reecting benefts

and harms o trial o labor compared to elective repeat

cesarean delivery are presented in bold ont and in

descending order o grade o evidence within this section.

SHORT-TERM OUTCOMES


None

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Studies operinatal mortality (death between 20 weeks o

gestation and 28 days o lie) are o moderate quality and

show that the perinatal mortality rate is increased or trial

o labor at 130 per 100,000 compared to elective repeat

cesarean delivery at 50 per 100,000. Although this dierence

is statistically signifcant, the magnitude o the dierence

between the two groups is small and comparable to

the perinatal mortality rate observed among laboring

nulliparous women. The neonatal mortality rate (death in

the frst 28 days o lie) is 110 per 100,000 or trial o labor

compared to 50 per 100,000 or elective repeat cesarean

delivery (Table 2). Table 2 puts into perspective the death

rates o babies in the population o women with prior

cesarean delivery, relative to other causes o death.

Table 2. Mortality Rates per 100,000 Infants

Overall

Trial of LaborPrior Cesarean

Delivery

Elective RepeatCesarean

Delivery PriorCesareanDelivery

All-cause mortality 20

weeks gestation to


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per 100,000. Elective repeat cesarean delivery may have

contributed to the reduction o stillbirths that occur in the

late third trimester and the decline in perinatal mortality

observed over the last two decades, because electiverepeat cesarean delivery is rarely perormed ater 40

weeks, whereas women who undergo trial o labor may

have longer gestations.

Hypoxic ischemic encephalopathy in term inants has

an incidence o 100 per 100,000 live births. That said, it

is considered one o the most catastrophic outcomes and

is one contributor to long-term neurological impairment

in inants. Such neurological damage is one o the most

serious adverse consequences o uterine rupture and a

major reason why women and clinicians are concerned

about electing trial o labor. The systematic evidence

review reported insufcient data on the incidence o

hypoxic ischemic encephalopathy between inants born

ollowing trial o labor compared with elective repeat

cesarean delivery. However, a recent observational study

o more than 33,000 women ound a signifcantly higher

incidence o hypoxic ischemic encephalopathy in trial o

labor compared with elective repeat cesarean delivery (12

cases versus 0 cases, respectively, or 46 per 100,000

or trial o labor compared with 0 per 100,000 or elective

repeat cesarean delivery). Unortunately, the studies on

this important outcome are limited by inconsistency in

study methodology.

Insufcient Evidence

Inants born by elective repeat cesarean delivery may

have higher rates orespiratory sequelae, including

respiratory distress syndrome, transient tachypnea o the

newborn, and need or oxygen and ventilator support

when compared to inants born by VBAC. There is a lack

o data to determine whether substantial dierences in

respiratory outcomes occur in inants born via elective

repeat cesarean delivery compared with inants born

ater trial o labor to women who had a prior cesarean.

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Studies osepsis were o low quality. No meaningul

conclusions could be drawn.

Inants born by elective repeat cesarean delivery are at

increased risk or birth trauma such as etal lacerations.Studies o brachial plexus injury (upper extremity nerve

injury) show an incidence o 180 per 100,000 in inants

born by VBAC compared to 30 per 100,000 among inants

born by elective repeat cesarean delivery. However, there

does not appear to be a substantial dierence in persistent

neurological impairment ater brachial plexus injury between

trial o labor and elective repeat cesarean delivery.

No comparative data exist on breasteeding practices

among women who had a prior cesarean delivery who

undergo trial o labor compared with elective repeat

cesarean delivery.

Comparative data regarding actors aecting mother-

inant bonding, including the long-term well-being o

the inant and early mother-inant contact, are lackingor women undergoing trial o labor or elective repeat

cesarean delivery.

5. What Are the Nonmedical Factors ThatInuence the Patterns and Utilization o

Trial o Labor Ater Prior Cesarean?We considered the inuence o the ollowing nonmedical

actors on practice and utilization patterns related to trial

o labor:

Proessional association practice guidelinesProessional liability concerns among physicians

and hospitalsThe nature and extent o inormed decisionmakingProvider and birth-setting issues

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Health insurance status and insurance reimbursementPatient and provider preerences.The literature syntheses that inormed this consensusconerence did not include these issues as part o the

evidence-based systematic review. Even so, we have

concluded that they are important inuences on access

to trial o labor. We have also concluded that data are

not available to judge therelative impact o these various

actors or how they interact.

Professional Association Practice Guidelines

In 1999, the American College o Obstetricians and

Gynecologists (the College) released a practice guideline

changing its earlier recommendation o encouraging

VBAC to a recommendation that women should be

oered trial o labor i there are no contraindications.

The guideline also stated that trial o labor should be

perormed only in institutions equipped to respondto obstetric emergencies and in settings where

physicians capable o perorming a cesarean delivery

are immediately available to provide emergency care.

According to the College, evidence to support this

guideline was rated as Level C (based on consensus and

expert opinion). Not all institutions were able to comply

with this new standard, which in turn led some to cease

oering trial o labor and thereore VBAC altogether.

Two recent surveys o hospital administrators ound that

30 percent o hospitals stopped providing trial o labor

services because they could not provide immediate surgical

and anesthesia services. Some have reerred to these

policies as VBAC bans. O the hospitals that still oer

trial o labor, more than hal had to change their policies

to comply with the 1999 College recommendation.

A joint statement by the American College o Obstetricians

and Gynecologists and the American Society o

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Anesthesiologists in 2008 also called or the immediate

availability o appropriate acilities and personnel,

including obstetric anesthesia, nursing personnel, and

a physician capable o monitoring labor and perormingcesarean delivery, including an emergency cesarean

delivery, in cases o vaginal birth ater cesarean delivery.

Even so, experts in tracking anesthesia sta resources

have ound that there are too ew anesthesia providers to

ensure immediate anesthesia availability or all hospitals

providing childbirth services. Moreover, they predict that

these shortages will worsen in the uture.

Professional Liability Concerns Among Physiciansand Hospitals

Concerns over liability risk have a major impact on the

willingness o physicians and healthcare institutions

to oer trial o labor. These concerns derive rom the

perception that catastrophic events associated with

trial o labor could lead to compensable claims withlarge verdicts or settlements or etal/maternal injury

regardless o the adequacy o inormed consent. Clearly,

these medical malpractice issues aect practice patterns

among healthcare providers and they played a role in the

genesis o the Colleges 1999 immediately available

guideline.

Members o the American College o Obstetricians andGynecologists confrm that concern over liability is a main

reason they stopped oering trial o labor. A 2009 College

survey revealed that 30 percent o obstetricians stopped

oering trial o labor or perorming VBACs because o

the risk or ear o proessional liability claims or litigation.

This is urther compounded by 29 percent acknowledging

having increased their number o cesarean deliveries and

8 percent having stopped practicing obstetrics altogether.In a recent study o College Fellows, risk o liability

was among the primary reasons cited or perorming a

cesarean delivery.

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In addition, studies have attempted to model the impact

o tort reorm on primary and repeat cesarean delivery

rates and have shown that modest improvements in the

medical-legal climate may result in increases in VBAC andreductions in cesarean deliveries. These analyses suggest

that both caps on noneconomic damages and reductions

in physician malpractice premiums would result in ewer

cesarean deliveries.

The Nature and Extent of Informed Decisionmaking

It is important that women understand the spectrum

o risks and benefts o trial o labor and elective repeat

cesarean delivery, given the evidence that providing such

inormation has a signifcant impact on a womans ability

to make an inormed choice about whether or not trial

o labor is a reasonable option or her. Several studies

suggest thathowrisk is presented and communicated

by providers has a powerul eect on womens decisions.

Along these same lines, the 1999 College guideline urged,Ater thorough counseling that weighs the individual

benefts and risks o VBAC, the ultimate decision to

attempt this procedure or undergo a repeat caesarean

delivery should be made by the woman and her physician.

Presentations at the conerence suggested that this

important recommended practice is not uniormly

ollowed, but there are no strong data documenting

the extent o this shortcoming.Patterns and use o trial o labor also may reect

womens varying levels o knowledge and appreciation

about the benefts and risks o the particular delivery

options available. More generally, there is limited public

understanding o the baseline risks o pregnancy and

childbirth in general.

A variety o decision aids are available to help womenunderstand the risks, benefts, and implications o trial

o labor compared with elective repeat cesarean delivery.

A ew well-designed studies suggest that certain tools

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can increase womens knowledge, reduce their anxiety,

and help them in their decisionmaking process.

Provider and Birth-Setting IssuesNo strong comparative data are available to assess

the relative impact o types o maternity care providers

(obstetrician-gynecologists, amily practice physicians,

midwives) on patterns and utilization o trial o labor ater

controlling or selection bias and patient mix.

Some evidence shows that younger obstetric providers

are less willing and interested in oering trial o labor.This may reect the act that their training occurred at

a time when trial o labor was steadily decreasing.

Women give birth in a variety o settings in and out o

hospitals, including tertiary care centers, community

hospitals, reestanding birth centers, and at home.

Most data on maternal and neonatal outcomes are

collected in tertiary care settings, which means thatthere is little data that assesses these outcomes

across numerous settings. However, there is a positive

association between settings with a high volume o

deliveries and better outcomes, especially lower rates

o neonatal mortality in premature inants.

Health Insurance and Reimbursement

Current data do not allow clear conclusions to be made

about the eect a womans health insurance status has

on her access to trial o labor. It also is not clear whether

overall reimbursement levels or VBAC compared with

elective repeat cesarean delivery have a major inuence

on either hospital or physician practice patterns.

Patient and Provider PreferencesAs a general matter, women report that their preerences

regarding delivery options are inuenced by their

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maternity care providers recommendations and concerns

about saety, including a desire or a healthy baby and

ear o a bad outcome.

Factors linked to womens preerence or pursuing trialo labor include sel-reported desire or their partners

involvement, a sense that labor and vaginal delivery

can be deeply empowering, maternal-inant bonding,

greater ease in breasteeding, and the expectation o an

easier recovery. Conversely, a desire or sterilization at

time o delivery, scheduling convenience, a preerence

or elective repeat cesarean delivery over emergency

cesarean delivery or operative vaginal delivery, the desire

to avoid labor pain, and ear o an unsuccessul trial o

labor have been identifed as reasons or preerring a

scheduled repeat cesarean delivery. The role o other

actors in womens preerencesincluding how the risk o

uterine rupture is viewed, sociodemographic status, social

norms, values, and beliesare less well understood.

With regard to health care provider preerences, ew dataexist to assess how obstetric providers view oering both

options (trial o labor and elective repeat cesarean delivery)

to their patients (holding other actors constant such as

liability concerns or past experience) and the conditions

under which they would eel comortable engaging their

patients in a thoughtul process o shared decisionmaking.

6. What Are the Critical Gaps in theEvidence or Decisionmaking, andWhat Are the Priority InvestigationsNeeded to Address These Gaps?

Critical gap 1: There is a need or uniorm and simple-

to-use defnitions that would be common to all datacollection. We recommend a standardized and systematic

use o defnitions or short-term and long-term maternal

and neonatal outcomes.

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Critical gap 2: There appear to be persistent racial/

ethnic, geographic, and socioeconomic dierences in

the rate o trial o labor and VBAC compared with elective

repeat cesarean delivery. We recommend investigation tounderstand the reasons or these dierences.

Critical gap 3: The actors that aect the course o labor

and its clinical management are incompletely understood.

We recommend well-designed clinical studies on practice

variation, provider type and setting, and intrapartum

management including induction methods. Methodologies

should be developed that address the challenges o

conducting studies based on plans or delivery, which

can change during the course o pregnancy.

Critical gap 4: Comparative long-term maternal and

perinatal biological and psychosocial outcomes ollowing

VBAC, unsuccessul trial o labor, and elective repeat

cesarean delivery are not well understood. We recommend

well-designed studies to identiy and describe these

outcomes so adverse consequences can be mitigatedor prevented.

Critical gap 5: The comparative eects that VBAC,

unsuccessul trial o labor, and elective repeat cesarean

delivery have on breasteeding practices are not well

understood. We recommend well-designed studies to

identiy these eects so adverse eects can be mitigated

or prevented.Critical gap 6:A variety o nonmedical actors aect

the availability and management o trial o labor, but

they have not been well studied. Access to sae trial

o labor appears to be restricted by actors such as

geography, workorce availability and training, proessional

association guidelines, type o maternity care provider,

liability concerns, health insurance, and institutional

policy. We recommend well-designed studies to better

understand these actors and to test clinical, institutional,

or policy interventions to increase access to sae trial

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o labor. Best practice models, such as those that

incorporate risk stratifcation in orming policies or

oering trial o labor and simulation training, should be

developed and careully assessed with an eye towardstheir widespread adoption.

Critical gap 7: The current medical-legal environment

including provider perceptions o and experience with

proessional liabilityexerts a chilling eect on the

availability o trial o labor. We recommend a series

o clinical and policy-relevant studies to develop

interventions to reduce this barrier.

Critical gap 8:The inormed consent process or trial

o labor and elective repeat cesarean delivery should be

evidence-based, minimize bias, and incorporate a strong

emphasis on the values and preerences o pregnant

women. We recommend interproessional collaboration to

refne, validate, and implement decisionmaking and risk

assessment tools, as well as inormed consent templates

that are inormative and reliable, and that can be welldocumented. These tools should also communicate

absolute risk in easily understood terms.

Critical gap 9: National and state-level surveillance o

actors associated with trial o labor are lacking. We

recommend that all states adopt the 2003 Standard

Certifcate o Live Birth and include questions in PRAMS

about decisions regarding method o delivery, laborinduction, and the role o the maternity care provider

and mother (and partner) in the decisionmaking process

rom early pregnancy through delivery.

Critical gap 10:There is insufcient inormation on

actors increasing VBAC among low-risk women.

We recommend high-quality clinical studies o well-

selected, low-risk women with sufcient statistical

power to characterize risks or unsuccessul trial

o labor in this population.

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Conclusions

Given the available evidence, trial o labor is a reasonable

option or many pregnant women with one prior low

transverse uterine incision. The data reviewed in this

report show that both trial o labor and elective repeat

cesarean delivery or a pregnant woman with one prior

transverse uterine incision have important risks and

benefts and that these risks and benefts dier or the

woman and her etus. This poses a proound ethical

dilemma or the woman as well as her caregivers,

because beneft or the woman may come at the price

o increased risk or the etus and vice versa. This

conundrum is worsened by the general paucity o high-

level evidence about both medical and nonmedical

actors, which prevents the precise quantifcation o

risks and benefts that might help to make an inormed

decision about trial o labor compared with elective

repeat cesarean delivery. We are mindul o these

clinical and ethical uncertainties in making the ollowingconclusions and recommendations.

One o our major goals is to support pregnant women

with one prior transverse uterine incision to make

inormed decisions about trial o labor compared with

elective repeat cesarean delivery. We recommend

clinicians and other maternity care providers use the

responses to the six questions, especially questions

3 and 4, to incorporate an evidence-based approachinto the decisionmaking process. Inormation, including

risk assessment, should be shared with the woman at

a level and pace that she can understand. When trial o

labor and elective repeat cesarean delivery are medically

equivalent options, a shared decisionmaking process

should be adopted and, whenever possible, the womans

preerence should be honored.

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We are concerned about the barriers that women ace in

gaining access to clinicians and acilities that are able and

willing to oer trial o labor. Given the low level o evidence

or the requirement or immediately available surgicaland anesthesia personnel in current guidelines, we

recommend that the American College o Obstetricians

and Gynecologists and the American Society o

Anesthesiologists reassess this requirement with specifc

reerence to other obstetric complications o comparable

risk, risk stratifcation, and in light o limited physician and

nursing resources. Healthcare organizations, physicians,

and other clinicians should consider making public theirtrial o labor policies and VBAC rates, as well as their

plans or responding to obstetric emergencies. We

recommend that hospitals, maternity care providers,

healthcare and proessional liability insurers, consumers,

and policymakers collaborate on the development o

integrated services that could mitigate or even eliminate

current barriers to trial o labor.

We are concerned that medical-legal considerations

add to, and in many instances exacerbate, these

barriers to trial o labor. Policymakers, providers, and

other stakeholders must collaborate in developing and

implementating appropriate strategies to mitigate the

chilling eect the medical-legal environment has on

access to care.

High-quality research is needed in many areas. Wehave identifed areas that need attention in response to

question 6. Research in these areas should be given

appropriate priority and should be adequately unded

especially studies that would help to characterize more

precisely the short-term and long-term maternal, etal,

and neonatal outcomes o trial o labor and elective

repeat cesarean delivery.

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Consensus Development Panel

F. Gary Cunningham, M.D.Panel and

Conerence ChairpersonBeatrice and Miguel Elias

Distinguished Chair inObstetrics and Gynecology

ProessorDepartment o Obstetrics and

GynecologyUniversity o Texas Southwestern

Medical Center at DallasDallas, Texas

Shrikant I. Bangdiwala, Ph.D.ProessorDepartment o Biostatistics,

Research TrackGillings School o Global

Public HealthUniversity o North Carolina

at Chapel HillChapel Hill, North Carolina

Sarah S. Brown, M.S.P.H.Chie Executive Ofcer

The National Campaignto Prevent Teen andUnplanned Pregnancy

Washington, DC

Thomas Michael Dean, M.D.Chie o Sta

Avera Weskota MemorialMedical Center

Sta PhysicianHorizon Health Care, Inc.Wessington Springs,

South Dakota

Marilynn Frederiksen, M.D.Associate Proessor o Clinical

Obstetrics and GynecologyFeinberg School o MedicineNorthwestern UniversityChicago, Illinois

Carol J. Rowland Hogue,Ph.D., M.P.H.

Jules & Uldeen Terry Proessor

o Maternal and Child HealthProessor o EpidemiologyDirectorWomens and Childrens CenterRollins School o Public HealthEmory University

Atlanta, Georgia

Tekoa King, CNM, M.P.H., FACNMAssociate Clinical Proessor

Department o Obstetrics,Gynecology, andReproductive Sciences

University o Caliornia,San Francisco

Deputy EditorJournal o Midwiery &

Womens HealthSan Francisco, Caliornia

Emily Spencer Lukacz, M.D., M.A.S.Associate ProessorClinical Reproductive MedicineUniversity o Caliornia,

San DiegoLa Jolla, Caliornia

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Laurence B. McCullough, Ph.D.Dalton Tomlin Chair in Medical

Ethics and Health PolicyProessor o Medicine and

Medical EthicsAssociate Director or EducationCenter or Medical Ethics

and Health PolicyBaylor College o MedicineHouston, Texas

Wanda Nicholson, M.D., M.P.H.,M.B.A.

Associate Proessor

Department o Obstetricsand GynecologyUniversity o North Carolina

at Chapel HillChapel Hill, North Carolina

Nancy Frances Petit, M.D.Chairperson, Division

o ObstetricsSt. Francis Hospital

Sta Obstetrician-GynecologistSt. Francis OB/GYN CenterNewark, DelawareFacultyUniormed Services University

o Health SciencesBethesda, Maryland

SpeakersDavid J. Birnbach, M.D., M.P.H.ProessorDepartments o Anesthesiology,

Obstetrics and Gynecology,and Public Health

Executive Vice ChairmanDepartment o Anesthesiology

Associate Dean and DirectorCenter or Patient SaetyMiller School o MedicineUniversity o MiamiMiami, Florida

Jerey Lynn Probstfeld, M.D.Adjunct Proessor o EpidemiologySchool o Public HealthProessor o Medicine (Cardiology)

Clinical Trials Service UnitUniversity o WashingtonSchool o Medicine

Seattle, Washington

Adele C. Viguera, M.D., M.P.H.Associate DirectorPerinatal and Reproductive

Psychiatry ProgramNeurological Institute

Cleveland ClinicCleveland, Ohio

Cynthia A. Wong, M.D.Proessor and Vice ChairpersonChie o Obstetrical AnesthesiaDepartment o AnesthesiologyNorthwestern UniversityFeinberg School o MedicineChicago, Illinois

Sheila Cohen Zimmet, R.N., J.D.Senior Associate Vice President

or Regulatory AairsGeorgetown University

Medical CenterWashington, DC

Emmanuel Bujold, M.D., M.Sc,FRCSC

Associate ProessorMaternal Fetal Medicine and

Perinatal EpidemiologyJeanne et Jean-Louis Lvesque

Research ChairDepartment o Obstetrics

and GynaecologyFaculty o MedicineLaval UniversityQubecCANADA

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Karen B. Eden, Ph.D.Investigator/Associate ProessorDepartment o Medical

Inormatics and Clinical

EpidemiologySchool o MedicineOregon Health and

Science UniversityPortland, Oregon

Cathy Emeis, Ph.D., CNMInvestigator/Assistant ProessorDepartment o Primary CareSchool o Nursing

Oregon Health andScience UniversityPortland, Oregon

Kimberly D. Gregory, M.D., M.P.H.Vice ChairpersonWomens Healthcare Quality and

Perormance ImprovementDepartment o Obstetrics

and Gynecology

Cedars-Sinai Medical CenterLos Angeles, Caliornia

William A. Grobman, M.D., M.B.A.Associate ProessorDivision o Maternal

Fetal MedicineDepartment o Obstetrics

and GynecologyFeinberg School o Medicine

Northwestern UniversityChicago, Illinois

Jeanne-Marie Guise, M.D., M.P.H.Principal Investigator/

Associate ProessorDepartments o Obstetrics

and Gynecology, andMedical Inormatics andClinical Epidemiology

School o MedicineOregon Health andScience University

Portland, Oregon

Lucky Jain, M.D., M.B.A.Richard W. Blumberg

Proessor and ExecutiveVice Chairperson

Department o PediatricsEmory UniversitySchool o Medicine

Atlanta, Georgia

Miriam Kuppermann, Ph.D., M.P.H.ProessorDepartments o Obstetrics,

Gynecology, & ReproductiveSciences, and Epidemiology

& BiostatisticsUniversity o Caliornia,San Francisco

San Francisco, Caliornia

Mark B. Landon, M.D.Proessor and DirectorDivision o Maternal-Fetal

MedicineDepartment o Obstetrics

and GynecologyThe Ohio State UniversityCollege o Medicine

Columbus, Ohio

Mona T. Lydon-Rochelle, Ph.D.,M.P.H., CNM

Associate Proessor andPerinatal Epidemiologist

National Perinatal

Epidemiology CentreAnu Research CentreDepartments o Obstetrics

and Gynaecology, andEpidemiology & Public Health

University College CorkCork University

Maternity HospitalCorkIRELAND

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Anne Drapkin Lyerly, M.D., M.A.Associate ProessorDepartment o Obstetrics

and Gynecology

Core FacultyTrent Center or Bioethics,Humanities, and Historyo Medicine

Duke UniversityDurham, North Carolina

George A. Macones, M.D., M.S.C.E.Proessor and ChairpersonDepartment o Obstetrics

and GynecologyWashington UniversitySchool o Medicine

St. Louis, Missouri

Howard Minko, M.D.Distinguished Proessor o

Obstetrics and GynecologyState University o New York

Downstate Medical Center

ChairpersonDepartment o Obstetricsand Gynecology

Maimonides Medical CenterBrooklyn, New York

T. Michael D. OShea, M.D., M.P.H.ProessorDepartment o PediatricsChie

Department o Neonatal& Perinatal MedicineNeonatology Division

o PediatricsSchool o MedicineWake Forest UniversityWinston-Salem, North Carolina

Rita RubinMedical Reporter

USA TODAYMcLean, Virginia

Caroline Signore, M.D., M.P.H.Medical OfcerPregnancy and

Perinatology Branch

Eunice Kennedy ShriverNational Institute o Child Health andHuman Development

National Institutes o HealthBethesda, Maryland

Robert M. Silver, M.D.Proessor and ChieDivision o Maternal-Fetal

MedicineDepartment o Obstetricsand Gynecology

University o UtahHealth Sciences Center

Salt Lake City, Utah

Michael L. Socol, M.D.Thomas J. Watkins

Memorial Proessor

and Vice ChairpersonDepartment o Obstetricsand Gynecology

Division o Maternal-FetalMedicine

Feinberg School o MedicineNorthwestern UniversityChicago, Illinois

Chet Edward Wells, M.D.

ProessorDepartment o Obstetricsand Gynecology

University o TexasSouthwestern MedicalCenter at Dallas

Dallas, Texas

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Planning Committee

Duane Alexander, M.D.Planning Committee

ChairpersonDirectorEunice Kennedy ShriverNa

tional Instituteo Child Health and HumanDevelopment


Caroline Signore, M.D., M.P.H.Planning Committee

ChairpersonMedical OfcerPregnancy and

Perinatology BranchEunice Kennedy Shriver

National Institute o Child Health and

Human DevelopmentNational Institutes o HealthBethesda, Maryland

Lisa Ahramjian, M.S.Communications SpecialistOfce o Medical Applications

o ResearchOfce o the DirectorNational Institutes o Health

Bethesda, Maryland

Shilpa Amin, M.D., M.Bsc., FAAFPMedical OfcerEvidence-based Practice

Centers ProgramCenter or Outcomes

and EvidenceAgency or Healthcare

Research and Quality

Rockville, Maryland

David J. Birnbach, M.D., M.P.H.ProessorDepartments o Anesthesiology,

Obstetrics and Gynecology,and Public Health

Executive Vice ChairmanDepartment o AnesthesiologyDirectorCenter or Patient Saety

and Associate Dean

Miller School o MedicineUniversity o MiamiMiami, Florida

Beth Collins Sharp, Ph.D., R.N.DirectorEvidence-based Practice

Centers ProgramCenter or Outcomes

and Evidence

Agency or HealthcareResearch and Quality

Rockville, Maryland

Paul A. Cotton, Ph.D., R.D.Program DirectorHealth Behavior and

Minority HealthDivision o Extramural ActivitiesNational Institute o

Nursing ResearchNational Institutes o HealthBethesda, Maryland

F. Gary Cunningham, M.D.Panel and Conerence

ChairpersonBeatrice and Miguel Elias

Distinguished Chair inObstetrics and Gynecology

ProessorObstetrics and GynecologyUniversity o Texas Southwestern

Medical Center at DallasDallas, Texas

Planning Committee members provided their input at a meeting heldAugust 1214, 2008. The inormation provided here was accurate at thetime o that meeting. 39


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Lata S. Nerurkar, Ph.D.Senior Advisor or the Consensus

Development ProgramOfce o Medical Applications

o ResearchOfce o the DirectorNational Institutes o HealthBethesda, Maryland

Judith P. Rooks, CNM, M.P.H., M.S.American College

o Nurse-MidwivesPortland, Oregon

Susan C. Rossi, Ph.D., M.P.H.Deputy DirectorOfce o Medical Applications

o ResearchOfce o the DirectorNational Institutes o HealthBethesda, Maryland

James R. Scott, M.D.Editor-In-Chie

Obstetrics and GynecologyProessor and Chair EmeritusDepartment o Obstetrics

and GynecologyUniversity o Utah

Medical CenterSalt Lake City, Utah

Robert M. Silver, M.D.ProessorDivision Chie o Maternal-Fetal

Medicine

Department o Obstetricsand GynecologyUniversity o Utah

Health Sciences CenterSalt Lake City, Utah

Catherine Y. Spong, M.D.ChiePregnancy and

Perinatology Branch

Eunice Kennedy ShriverNational Institute o Child Health andHuman Development


Linda J. Van Marter, M.D., M.P.H.Associate Proessor

o Pediatrics

Harvard Medical SchoolChildrens HospitalBoston, Massachusetts

Planning Committee members provided their input at a meeting heldAugust 1214, 2008. The inormation provided here was accurate at thetime o that meeting. 41


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Conerence Sponsors

Eunice Kennedy Shriver Ofce o Medical Applications

National Institute o o ResearchChild Health and Human Jennier M. Croswell, M.D., M.P.H.Development Acting Director

Alan Guttmacher, M.D.Acting Director

Conerence Cosponsors

National Institute o Ofce o Research on

Nursing Research Womens HealthPatricia Grady, Ph.D., R.N., Vivian W. Pinn, M.D.

FAAN Associate Director or ResearchDirector on Womens Health

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