VBAC: Are cost concerns outweighing possible safety risks?
Study finds complications almost twice as high in repeat cesareans
A new study of patients undergoing vaginal birth after cesarean section (VBAC) indicates the rate of serious complications is higher among those women than in patients who elect to have a second cesarean section.1
The study is cause for concern because in the cost-conscious 1990s, the trend has been to encourage VBACs over cesarean sections whenever possible. Experts say that patients should always have the option of deciding whether they want to have VBAC or a cesarean section. They also point to clear contraindications for a trial of labor in a patient who has had a previous cesarean.
Michael J. McMahon, MD, MPH, assistant professor of obstetrics and gynecology at the University of North Carolina in Chapel Hill, led the study of 3,249 women who elected a trial of labor and 2,889 women who chose to undergo a second cesarean section. The overall rate of minor maternal complications such as puerperal fever or abdominal wound infection didn’t differ significantly between the two groups of women, but major complications were almost twice as likely to occur in women undergoing a trial of labor. The major complications were as follows:
• Hysterectomy occurred in five (0.2%) patients undergoing trial of labor compared to six (0.2%) patients undergoing elective cesarean section.
• Uterine rupture occurred in 10 (0.3%) patients undergoing trial of labor compared to one undergoing elective cesarean section.
• Operative injury occurred in 41 (1.3%) patients undergoing trial of labor compared to 18 (0.6%) patients undergoing elective cesarean section.
McMahon tells Hospital Case Management that he was surprised by the findings, because the assumption is that cesarean sections cause more complications than vaginal deliveries. But in general, he says women who are older than age 35 carrying infants who weigh less than 4,000 grams and who give birth in tertiary care facilities are less likely to have complications during VBAC. He explains that women over the age of 35 are more likely to have had previous pregnancies with or without cesarean section and higher parity decreases the risk of complications during labor and delivery, McMahon says. As for the other two factors, smaller babies are less likely to create delivery complications, and clinicians at tertiary care hospitals are more experienced in dealing with difficult deliveries.
Are specialty hospitals necessary?
But that doesn’t mean less-experienced hospitals shouldn’t care for VBAC patients. What predicts success is that patients are cared for in facilities that have adequate protocols in place with well-trained nurses and physicians, he adds.
"VBACs need to happen in the real world the community centers and not just tertiary care centers," McMahon notes. "Truly it gets down to education. As long as the facility is supportive, you have anesthesia available, you have nursing staff that’s been educated, and you have physicians who are comfortable doing it, then I think [VBACs] are acceptable. It’s important to understand what a uterine rupture is and that VBAC is not low-risk."
For example, nurses should know the signs of uterine rupture such as fetal bradycardia and sudden onset of severe lower abdominal pain.
"That’s important, because there are minutes between life and death with those babies," McMahon says.
McMahon advocates practice guidelines published in 1995 from the American College of Obstetricians and Gynecologists, which outline the contraindications for VBAC delivery.2 (See related article, p. 164.) The guidelines are part of critical paths in development at the University of North Carolina Hospital for normal vaginal delivery, says Pat LaFountain, RNC, MN, nurse manager of labor and delivery. There will be no special critical path for VBACs.
"Now, everybody who comes in, unless they’re a scheduled C-section, will go on that critical path for normal vaginal delivery," she notes.
If nurses note problems such as "unremitting pain" and abdominal rigidity, LaFountain says they know to contact a physician immediately.
How to get C-section rates down
Even if critical paths don’t need to address the issue of VBACs vs. cesarean sections, hospitals have to for monetary reasons. Chris Daley, RNC, MN, CNAA, clinical nurse educator at Tucson (AZ) Medical Center, says that last year the cesarean rate at the facility was in the 25% range. Many patients are high risk; the hospital cares for a large indigent population that crosses the border from Mexico.
But this year, the cesarean section rate is down in the 18% range.
"That’s $100,000 a month [in savings]," she says. "When you add that up, it’s incredible."
She says physicians educate patients early during their pregnancy that they can safely have vaginal deliveries, which has helped bring cesarean rates down. A quality improvement team consisting of nurses, physicians, midwives, and anesthesiologists met to try to figure out ways to decrease cesarean section rates. Many physicians are part of the hospital’s own HMO, Daley adds.
"A lot of that was based on cost, but we know that this is still patient-focused care," Daley explains. "We know that maternal deaths are higher in cesareans."
Recently passed federal legislation will mandate that women undergoing vaginal delivery be allowed to stay in the hospital for 48 hours, and women undergoing cesarean sections be allowed to stay for 96 hours. Daley says that, too, will drive costs back up, but not all patients will take advantage of it.
"What we’ve seen happening is that a doctor was wanting a patient to stay longer because she needed education, and the third-party payer would deny it even though it was a medical indication," she explains. "Now, if a woman doesn’t know how to take care of her baby and has a knowledge deficit, she can stay longer, or get an extra home health visit. But women who are ready to go home earlier can."
Is pendulum swinging back around?
Sylvia Wood, RN, MSN, assistant professor of nursing at Pacific Lutheran University in Tacoma, WA, and immediate past president of the Association of Women’s Health, Obstetrics, and Neonatal Nursing in Washington, DC, says she has seen the pendulum swing back on the issue of cesarean sections and VBACs in the last decade or more. Wood says she hopes physicians don’t start going back to doing more cesarean sections as a result of the study because the data do not support that approach.
"It used to be, Once a cesarean, always a cesarean,’" Wood notes. "Now, it’s not at all uncommon even if the woman has had more than one C-section to see lenience toward VBAC. This study may cause [physicians] to reconsider that."
But McMahon says that would be a mistake. "Some people have interpreted this study as saying that we shouldn’t advocate VBAC," he says. "That’s the exact opposite of what we’re saying in the paper. The point of the paper was to say that problems do occur, and the pendulum shouldn’t swing back so far to the right that women are mandated first into a trial of labor when, in fact, they might be at high risk to fail.
"What we’re saying is as we encourage VBACs, we have to absolutely make sure that we’re doing the right thing," he adds. "There are a group of women who when they don’t make it through the labor the second time have major problems. They might need counseling against a trial of labor. And if it’s their desire after counseling to elect surgery, we need to listen to them and go with their decision."
References
1. McMahon MJ, Luther ER, Watson AB, et al. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996; 335:689-695.
2. American College of Obstetricians and Gynecologists. ACOG Practice Patterns August 1995; pp. 1-8.
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