Approach VBAC deliveries cautiously, experts say
AFMC project ensured quality safety
Many of Arkansas's participating ORYX hospitals are using their rates of cesarean deliveries and vaginal births after cesarean (VBACs) as performance measures to demonstrate their ongoing performance improvement to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Contrary to traditional views advocating "once a cesarean, always a cesarean," recent studies indicate that 60% to 80% of women who attempt to deliver vaginally following one or more previous cesareans succeed.1,2
"We encouraged facilities in our performance improvement project to educate their patients about VBAC because a lot of people still believe what their moms told them about C-sections having to follow C-sections," says Sandy Grinder, RN, BSN, CPHQ, Health Care Quality Improvement Program Director at the Arkansas Foundation for Medical Care (AFMC) in Fort Smith. Grinder says trials of labor are particularly appropriate for patients who have had previous breech presentations and who have had low uterine incisions for their previous cesareans, as the incidence of uterine rupture is similar to that seen in patients who have had cesarean alone.3
Not all women are candidates for VBACs, however. An increasing trend in the use of vertical incision and inverted T incisions for preterm cesareans raises concerns about increased risk for uterine rupture. Trials of labor in those patient categories should be carried out with caution and according to current recommendations.4
In addition, a critical ingredient of a successful VBAC program is the ability to do a cesarean within 30 minutes on any woman in labor. Some small rural facilities do not have the personnel available to meet this standard.
"No question, vaginal delivery is a little more difficult once a woman has had a C-section. A lot depends on the type of incision done previously," says Grinder. "It's imperative to have enough staff available to handle whatever might come up during delivery." AFMC's project had to ensure quality measures were in place to make sure VBAC was a safe route. Staffing levels had to be adequate, and if they weren't, project personnel encouraged those facilities to transfer patients to other, better-equipped hospitals. Grinder says a 50-bed facility in rural Arkansas would probably be too small, but even a 100-bed facility there might not have sufficient staff to perform VBACs safely.
References
1. Flamm BL, Newman LA, Thomas SJ, et al. Vaginal birth after cesarean delivery: Results of a five-year multicenter collaborative study. Obstet Gynecol 1990; 76:750-754.
2. Miller DA, Diaz FG, Paul RH. Vaginal birth after cesarean: A 10-year experience. Obstet Gynecol 1994; 84: 255-258.
3. Naef RW, Ray MA, Chauhan SP, et al. Trial of labor after cesarean delivery with a lower-segment, vertical uterine incision: Is it safe? Am J Obstet Gynecol 1995; 172:1,666-1,674.
4. American College of Obstetricians and Gynecologists. Committee on Obstetrics. Maternal and Fetal Medicine. Guidelines for Vaginal Delivery After a Previous Cesarean Birth. Washington, DC; 1988.
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