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  • Amy Saloner

From the NIH Consensus Development Program; an important word about VBACs...

The (NIH) panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

Conclusions: Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.The data reviewed in this report show that both trial of labor and elective repeat cesarean delivery for a pregnant woman with one prior transverse uterine incision have important risks and benefits and that these risks and benefits differ for the woman and her fetus. This poses a profound ethical dilemma for the woman as well as her caregivers, because benefit for the woman may come at the price of increased risk for the fetus and vice versa. This conundrum is worsened by the general paucity of high-level evidence about both medical and nonmedical factors, which prevents the precise quantification of risks and benefits that might help to make an informed decision about trial of labor compared with elective repeat cesarean delivery. We are mindful of these clinical and ethical uncertainties in making the following conclusions and recommendations.

One of our major goals is to support pregnant women with one prior transverse uterine incision to make informed decisions about trial of 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 approach into the decision-making process. Information, including risk assessment, should be shared with the woman at a level and pace that she can understand. When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman’s preference should be honored.

We are concerned about the barriers that women face in gaining access to clinicians and facilities that are able and willing to offer trial of labor. Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Health care organizations, physicians, and other clinicians should consider making public their trial of labor policies and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor.

We are concerned that medical-legal considerations add to, and in many instances exacerbate, these barriers to trial of labor. Policymakers, providers, and other stakeholders must collaborate in developing and implementating appropriate strategies to mitigate the chilling effect the medical-legal environment has on access to care.

High-quality research is needed in many areas. We have identified areas that need attention in response to question 6. Research in these areas should be given appropriate priority and should be adequately funded – especially studies that would help to characterize more precisely the short-term and long-term maternal, fetal, and neonatal outcomes of trial of labor and elective repeat cesarean delivery.

To read the complete statement as outlined below (in PDF), click here.

Introduction

  1. What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birthafter cesarean, and repeat cesarean delivery in the United States?
  2. Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
  3. 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?
  4. 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?
  5. What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
  6. What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?

Conclusions

Panel

Speakers

Planning Committee

Sponsors

Additional Information

Topics: VBAC, c section