Vaginal Birth after Cesarean: Still a Viable Option

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Vaginal Birth after Cesarean Still a Viable
Option?

• Michele R. Lauria, MD, MS
• Associate Professor Ob/Gyn and Radiology
• Dartmouth Hitchcock Medical Center
• Medical Director NNEPQIN

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Objectives

• Discuss the evidence and controversy that
  continue to exist around VBAC as a delivery
  option
  
• Describe NNEPQIN's tools for increasing the
  availability and patient and provider safety of
  VBAC in the northeast US.
  
• VBAC Guidelines,
• Consent for Birth After Cesarean Section, and 3)
  Birth
  
• Choices after a Cesarean Section.

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Outline

• History of VBAC
• National guidelines
• Literature Review
• NNNEPQIN Guidelines
• Practical Application

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Uterine Rupture (UR)

• Williams Obstetrics Separation of the old
  uterine incision throughout most of its length,
  with rupture of the fetal membranes so that the
  uterine cavity and the peritoneal cavity
  communicate. In these circumstances, all or part
  of the fetus is usually extruded...
• Research Definition
• Complete disruption of all uterine layers AND 1
• intraperitoneal or vaginal hemorrhage
• Need for hysterectomy
• Bladder injury caused by scar disruption
• Extrusion any portion of fetal-placental unit
• C/S for non-reassuring FHT or or suspected UR

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Uterine Dehiscence
Williams Obstetrics ... fetal membranes are not
ruptured and the fetus is not extruded into the
peritoneal cavity ...
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History of Availability

• 1980s 30 minute rule
• ACOG, ASA, AAP
• Cesarean delivery personnel onsite within 30
  minutes of the decision
  
• 1990 JCAHO adopts 30 minute rule
• 1999 ACOG Practice Bulletin immediately
  available
  
• 2000 Local Definition ACOG ASA
• 2001 JCAHO adopts same language
• 2001 Lydon Rochelle
• 2002 VBAC services start closing
• 2002 VT/NH VBAC project completed
• 2004 ACOG publishes new guidelines
• 2005 Landon MFMU Network Study

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ACOG 2000

• VBAC is an elective procedure
• in institutions equipped to respond to
  emergencies with physicians immediately available
  to provide emergency care.
  
• ... definition of immediately available personnel
  and facilities remains a local decision based on
  each institutions available resources and
  geographic location.

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ACOG and the American Society of
Anesthesiologists 2001

• Availability of anesthesia and surgical
  personnel to permit the start of a cesarean
  delivery within 30 minutes of the decision to
  perform the procedure in cases of vaginal birth
  after cesarean delivery (VBAC), appropriate
  facilities and personnel, including obstetric
  anesthesia, nursing personnel, and a physician
  capable of monitoring labor and performing
  cesarean delivery, immediately available during
  active labor to perform an emergency cesarean
  delivery. The definition of immediately
  available personnel and facilities remains a
  local decision based on each institutions
  available resources and geographic location.
• ACOG Committee Opinion, 256, May 2001

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Areas lacking VBAC support 10/2005
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National Total CS, Primary CS, VBAC
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Declining VBAC Rate

• Definition Vaginal delivery rate for all women
  with prior cesarean
  
• Proportion eligible
• Proportion attempting
• Proportion successful
• Declining rate of attempts
• Closed hospitals
• Patient/provider preference

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Declining Attempts

• Negative publicity lay and medical press
• Lyndon-Rochelle Higher rate UR with
  Prostaglandins than prior reports
  
• Large Med-mal awards, rising premiums, refusal to
  insure
  
• Ambiguous definitions/standards
• Immediately Available
• ACOG Locally defined in communications
• Elective primary cesarean movement
• Home Birth VBAC

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Social/Economic Impact

• C/S is 3rd most common procedure in NH
• ERCS accounts for 38 of all C/S
• HCCUP Data 3,785 for C/S vs SVD
• NH VT 372 extra C/S 2002
• 1,408,020
• Litigation
• 7 M/adverse neonatal outcome from UR
• No choice for many women
• Nearest hospital offering VBAC 1 hour away
• Prior successful VBAC forced to C/S

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ACOG Guidelines 2004

• No randomized trials TOL vs ERCS
• Most studies tertiary or university centers
• VBAC candidates are
• One prior LTCS
• No other uterine scars or prior UR
• Clinically adequate pelvis
• MD in active phase capable of monitoring and c/s
• Available anesthesia and personnel for emergency
  c/s

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ACOG 1 Prior C/S

• UR risk 1-3.7
• If control for confounders, 5 fold increase UR
  (2.5)
  
• Based on a single study
• If 2 prior c/s and prior vaginal delivery
• ¼ as likely to have a UR
• These are candidates

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Contraindications for VBAC

• Prior classical, T or extensive transfundal
  uterine surgery
  
• Previous UR
• Inability to perform an emergency cesarean
  delivery
  
• 2 prior c/s and no prior vaginal deliveries

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• Equipped to respond to emergencies with MD
  immediately available to provide emergency care
  
• After counseling, decision by patient and her
  physician
  
• Document in medical record

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RISK ASSESSTMENT
ALL VBACS ARE NOT EQUAL
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Risks for Uterine Rupture

• Clearly Increased 2 well done studies
• Pitocin
• Prostaglandins
• 2 or more prior cesarean sections
• Dystocia
• Possibly Increased 1 study
• AMA
• Single layer closure (1 says yes, the other no)
• Mechanical methods of ripening
• No Increase 2 studies evaluating
• But may increase the risk of dystocia
• Epidural
• Macrosomia
• Gestational Age
• Indication prior c/s

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Summary UR

• Uterine Rupture
• Rageth Ravasia LR Mozur Landon
• No h/o CS 0.0075
• ECS 0.19 0.16
  0.16
  
• SOL 0.40 0.45 0.52
  0.4
  
• IOL Prost 2.9 2.45
  1.4
  
• IOL Pit 0.73
  0.77 1.1
  

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Signs of UR

• Unrecognized dystocia 40 of cases
• 2 case control studies US and Canada
• Average length arrest disorder 5 hours
• Repetitive variable or late decelerations
• Abnormal FHR pattern in 70-80
• Decreases time until neonatal injury
• Pain is a late and rare finding
• Bradycardia is a late finding
• Abruption decreases time

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EFM and Uterine RuptureNonreassuring fetal
monitoring tracing is the 1st sign

• Variable decelerations progressing to bradycardia
  in 50 minute timeframe
  
• The most typical pattern in uterine rupture

Ann Darlington, CNM
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EFM and Uterine Rupture

• Regular, then sudden cessation of contractions

Ann Darlington, CNM
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EFM and Uterine Rupture

• Recurrent late decelerations and decreased
  variability over 2 hours time frame
  
• Pitocin induction
• Placenta delivered with infant
• (Images from JOGNN, 33, 105-115 2004)

Ann Darlington, CNM
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32 Minutes
10 Minutes
Leung et al, Am J. OB/GYN 1993
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Fetus Risks ERCS

• Respiratory vs Vag Delivery Levine
• TTN 3.5 vs 1.1 p
• RDS 0.2 vs 0.1 NS
• PFC 0.37 vs 0.08 p
• Respiratory vs TOL Hook
• TTN 6 vs 3
• Any respiratory complication RR 2.3 (1.4, 3.8)

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Fetus failed VBAC vs ERCS

• Increase infectious morbidity
• Hook 2 vs 0 (3 cases vs 0) proven sepsis
• Hook 12 vs 2 suspected sepsis
• Hook surprising number of routine VD have extra
  procedures done. Need for control group.

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UR Risk of Fetal Death/Injury

• Make sure they were all alive at start
• Need standardized assessments of injury
• Yap 0/19 intrapartum MM
• Lueng 2/86 death, 4/86 asphyxia
• Farmer 1/61 death
• LR 5/91 death
• Bujold 1/23 death, 2/23 ? Asphyxia
• Overall 3.2 risk death, 5.5 injury
• Standard quote 10

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The Plague of VBAC Studies

• Are all live, non-anomalous fetuses?
• more aggressive with IUD, CM
• Ascertainment bias
• After TOL more likely to call defect a UR
• ICD-9 codes inaccurate (NH, MA x2)
• 50 not UR, include extensions, more likely with
  TOL
  
• 50 not symptomatic UR
• Temporal trends with declining PVP
• What do you compare complications to?
• How is the denominator determined
• Are all really TOL candidates
• How many prior classical c/s or unknown scars
  included
  
• How many had 2 cesarean deliveries?

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Methodology

• Prospective observation study (level B)
• 4 years 1999-2002
• All women with a prior cesarean delivery
• 17,898 TOL vs 15,801 ERCS
• TOL presenting in labor at 4 cm or receiving
  pit
  
• If presented in early labor and having c/s were
  excluded because couldnt tell if they were
  planned ERCS
  
• ERCS no medical indication ie classical or
  maternal health
  
• 19 academic medical centers
• Research nurses collecting data

Landon et al NEJ 2004
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Patient Population

• 378,168 birth during the study period
• 45,988 women singleton gestation with prior c/s
• 38.9 N 17,898 TOL
• 34.4 N 15,801 ERCS
• 23.7 N 12,289 excluded
• 9013 had indicated repeat c/s
• 7.1 N 3276 women presented in early labor
  without a plan documented
  
• Rate of TOL
• Range 18.7-63.2
• Overall 48.3 1999 declining to 30.7 2002
• Success Rate 73.4

Landon et al NEJ 2004
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Rates of UR by Labor Status
Landon et al NEJ 2004
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Maternal Complications
UR includes 2/102 with low vertical incision and
2/105 with classical/T/J incisions
Landon et al NEJ 2004
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Maternal Outcomes by TOL Success
Landon et al NEJ 2004
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Perinatal Outcomes Term Infants
Landon et al NEJ 2004
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Perinatal Outcome with UR
Landon et al NEJ 2004
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Excess Morbidity/Mortality TOL

• Exclude antepartum SB as increased anomalous
  fetuses in TOL
  
• 0.16 TOL vs 0.05
• Excess of 0.1 or 1/1000
• Not all excess related to uterine rupture
• Increased still birth
• Anomalies
• More postdate pregnancies
• 7/12 HIE associated with UR 2 died
• Overall, 7/15,338 (0.045) or 1/2000 risk of
  adverse neonatal event due to UR.
  
• Risk NND from TOL vs ERCS Cant determine NND
  since anomalies and PTD included
  
• Risk HIE from TOL vs ERCS 0.08 or allmost
  1/1000

Landon et al NEJ 2004
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MFMU Multiple vs Single C/S Risk of UR

• Multiple c/s UR rate 0.9 (9/975)
• Single c/s UR rage 0.7 (115/16915
• P0.37
• Multivariate analysis controlling for IOL,
  pitocin, prior vaginal delivery confirmed the
  finding
  
• Increased maternal morbidity with multiple c/s vs
  single
  
• Hysterectomy 0.6 vs 0.2 p0.23
• Transfusion 3.2 vs 1.6 p
• Increased composite maternal morbidity with TOLAC
  vs ERCS in multiple c/s group
  
• Increased composite maternal morbidity
• OR 1.41 (95 CI 1.02-1.93)

Landon 2006 Obstet Gyencol 10812
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Maternal Complications Associated With Multiple
Cesarean Deliveries

• Retrospective cohort study N277 2 cs with
  N491 2 cs
  
• More than 2 cs associated with
• Excessive blood loss 7.9 versus 3.3 P
• Difficult delivery of the neonate 5.1 versus
  0.2 P
  
• Dense adhesions 46.1 versus 25.6 P
• Proportion of women having any major complication
  P
  
• 2 cs 4.3
• 3 cs 7.5
• 4 or more cs 12.5
• accreta risk with 4 4.7 vs 0.6 p

Nisenblat obstet Gynecol 2006 10821-6
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When Does VBAC Make Sense?
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• Points of view
• Patient Out of pocket, time from work and
  family, loss of function, long term care
  
• Provider Time out of office, med mal,
  insurance
  
• Payer Actually paid to hospital for mom and
  baby
  
• Society as a whole
• Use Bottom Up or Micro-costing for Hospital
  Costs
  
• Vaginal Delivery 4950
• ERCS 7,244
• Failed TOL 8,414
• Any major complication mom or baby extra 6000

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Results

• TOL is cost-effective if
• Probability success 0.74
• Costs of failed TOL exceed ERCS
• Include costs of folks on stand by
• TOLAC is not significantly cost saving!

Macario Clinical Obstetrics and Gynecology
47378-85 2004
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• TOL is cost effective if
• Success 50
• 10-20 chance of wanting another child
• Delayed risks of cesarean section are greater
  than its immediate benefit
  
• Risks of previa, abruption etc

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Predicting a Successful TOLAC
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Predicting vaginal brith after cesarean delivery
A review of prognostic factors and screening
tools Hashima AJOG 190547-55

• Medline/HealthSTART search
• 13 of 100 studies fair to good quality on 12
  factors
  
• 2/6 screening tools had been validated
• Conclusions
• Little high quality data
• Tools need to be user-friendly
• Need research to determine clinical setting best
  in
  
• Should be national research priority

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Predicting vaginal birth after cesarean delivery
A review of prognostic factors and screening
tools Hashima AJOG 190547-55

• Significant Factors Increasing Success
• prior VD
• If prior VD after c/s
• GA
• Birth weight
• Dilation
• Effacement
• Flamm 1997 best article
• Developed on n2502
• Tested on n2501

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Can a scoring system predict VBAC success?Flamm,
Obstet Gynecol 199790907-10
TOTAL 10
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Performance of scoring system Flamm, Obstet
Gynecol 199790907-10
Note 50 success even with score 0-2
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Flamm 1997

• 18 predicted low likelihood
• Score 0-3
• False-negative ratio 10
• 253/2405 incorrectly advised to have C/S when
  could have had VD
  
• False-positive ratio 2.6
• 63/2405 fail TOL after being told to try

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Induction of labor after one prior cesarean
predictors of vaginal deliveryGrinstead Obstet
Gynecol 103534-8

• Retrospective review 429 charts
• All IOL
• Predictors poor success
• CD for dystocia
• GA 40 weeks
• Unfavorable cervix
• Any type diabetes

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Chance of VBAC in women undergoing IOL for TOLAC
Overall 77.9 success rate Retrospective chart r
eview of N429 at Northewestern
OVD rate of 14.1
Grinstead Obstet Gynecol 103534-8, 2004
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Macario Clinical Obstetrics and Gynecology
47378-85 2004
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Results Predictors of Failed TOL

• Women without prior VD
• MA 35
• Insulin requiring DM
• Prior c/s for dystocia
• IOL
• Cervical ripening
• Birth weight 4000g
• Actual birth wt prior birth wt
• Women with prior VD
• MA 35
• Birth weight 4000g

Bujold Am J Ob/Gyn 190113-8, 2004
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• Retrospective chart review 1995-6 16 hospitals
• N9960
• Singleton with 1 prior CD
• Risk groups based on number and timing of vaginal
  deliveries
  
• If no prior VD
• decrease success with birth weight
• Increase UR with birth weight 4000 grams
• If prior VD no effect of birth weight

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MFMU Factors affecting the success of TOLAC

• Increased likelihood of successful VBAC
• Prior vaginal delivery
• C/s for malpresentation or non-dystocia
• Birth weight
• BMI
• SOL
• Cervical dilation 4 cm on admission
• Obese women, without prior vd, requiring
  induction
  
• Only those with prior c/s for malpresentation
  have success rate 50

Landon Am J Obstet Gynecol 2005 1931016
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MFMU Development of a Nomogram for predicting
successful TOLAC

• ROC Area under the curve 75.4
• With validation data set, ROC area unchanged

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MFMU Development of a Nomogram for predicting
successful TOLACGrobman Obstet Gynecol 2007
109806
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TwinsLandon MFMU

• Sub-analysis of prior study
• N412 twins, 45.1 had a TOL
• VBAC success rate 64.5
• Of the 66 women with failed TOL, 30 had vaginal
  delivery of A with c/s of B.
  
• 9 Vtx/Breech
• 21 Breech/Breech
• For women with TOL
• No increase adverse maternal outcome vs ERCS
• With GA adjustment, neonatal outcomes similar
• Rate of UR was 1.1

Am J Obstet Gynecol 193135-140
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Sonographic Thickness of the LUS

• Rozenberg Lancet 1996
• N642 prior c/s prospectively followed
• LUS
• Sensitivity 88, specificity 73, PPV 12, NPV
  99
  
• 5 follow up validation studies, all with single
  sonographer
  
• Jastrow Ultrasound Obstet Gyecol 2006
• Intraobserver variability 1mm
• Interobserver variability poor with TAUS, high
  with TVUS
  
• However TAUS did not compare with TVUS, so
  unclear what cut off should be used with TVUS

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VT/NH VBAC Procject

• Goal Increase VBAC availability and safety for
  patients and providers
  
• Collaborative Creation Regional
• Protocol
• Consent form
• Patient Education Tool
• October 4, 2002 Official Release
• September 2005 Update
• Matches resources to risk

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VT/NH VBAC Project Process

• All Hospitals NH and VT
• OB, anesthesia, administrators, med mal and
  health insurers, nursing, public health
  departments, home birth midwives
  
• 180 first meeting, 50 for 5 follow up
• April 22 2002 Literature review
• Combined materials from all hospitals
• 5 Follow ups Open collaboration
• Tools
• Guideline
• Patient Education Document
• Consent Form

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Guideline

• Rigorous definitions
• Admission
• OR personnel
• Anesthesia personnel
• Matches resources to risk
• Of UR
• Of fetal injury
• No times
• Defines availability by location and activity
• Advises against use of prostaglandins

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Guideline

• Low Risk SOL, 1 c/s, normal tracing
• Notify anesthesia, OR, Pedi of admission
• OB on campus active phase
• Medium risk 2 c/s, augmentation, IOL,
• Anesthesia on campus active phase
• OR on campus active phase or plan in place if OR
  busy

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Guideline

• High Risk Definition
• Abnormal FHR pattern, not resolving
• No change in 2 hours despite adequate labor
• Bleeding like an abruption
• High Risk Resources
• Everyone available
• No other acute patient care responsibilities

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What is NNEPQIN Doing

• PCOS Study
• Registry of resource utilization, risk escalation
  and outcome in women with prior c/s
  
• Prospectively filled out data sheet
• Updated Guidelines 2005
• WWW.NNEPQIN.Org

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PCOS Study Design

• Observational, Cross-sectional study from
  2004-2007
  
• Questionnaire completed at time of delivery
• Community and Tertiary Care Centers
• Voluntary participation
• Designed as a Quality Assurance/Quality
  Improvement Project of NNEPQIN
  
• IRB approval
• Subjects All women with a prior cesarean
  section presenting for delivery
  
• No Exclusion Criteria

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Answer the following questions for all women
with a prior cesarean section
additional resources used
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Statistical Analysis

• Power calculation setting a0.05 and b0.2,
  requires n204 to detect an absolute difference
  of 20 assuming one third attempt TOLAC
  
• Statistical tests Fishers exact, Pearsons chi
  square, clustered multivariable logistic
  regression
  
• Odds Ratios with 95 confidence intervals were
  calculated to describe the effect of anticipated
  mode of delivery on resource use
  

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Outcome Variable

• Composite Resource Use
• OR Personnel
• Anesthesia Personnel
• OR Cases
• Work-Flow of the OB Unit

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Proportion of Submissions

• 279 Deliveries

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Patient Characteristics
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Clustered Multivariable Analysis
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Conclusions

• TOLAC, compared to ERCS, does not require
  additional hospital resources
  
• Factors associated with additional hospital
  resource use include 1) need for stat or urgent
  cesarean section, 2) occurrence of maternal
  complications, 3) preterm birth, or 4) community
  hospital setting

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Implications

• Adoption of policies against TOLAC is unlikely to
  reduce the resources hospitals expend in caring
  for women with prior cesarean sections