Trial of labor vs. repeat cesarean: Let Mom decide
Insurers, AAFP, and ACOG advice similar
Employer groups and large insurers are scrutinizing hospitals’ and physicians’ C-section rates, and awarding contracts based on what they find. They reference a fivefold increase in the rate of C-sections over the past 25 years with no improvement in fetal or maternal outcomes. Of the 4 million babies born each year in the United States, almost 1 million are born by C-section.
Bottom-line advice of the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) is that a woman should be given information on both delivery methods and encouraged to undergo a vaginal delivery, but her preference for an elective repeat cesarean section (ERCS) should be respected. The organizations base their recommendations on recent studies on trial of labor (TOL) vs. ERCS.
Studies in recent years on vaginal birth after C-section (VBAC) have focused primarily on risk of rupture and probability of successful delivery. A task force created by the AAFP set out to establish a policy that would combine evidence-based outcomes, patient preferences, and cost.1
Their findings:
• Two-thirds of women interviewed during the last trimester of pregnancy preferred TOL over ERCS.
• Mean length of stay for women undergoing TOL was 2.94 days, and 4.11 days for women undergoing ERCS.
• Infants born vaginally stayed in the hospital for 2.99 days, and those born by C-section stayed 4.96 days.
• Hospital charges differ by region and are greater in metropolitan areas, but tend to be 1.7 to 2.4 times greater for C-section than for vaginal delivery.
• Each C-section averages an additional $3,500 charge per delivery.
After taking these findings into consideration, the AAFP concludes that an informed mother should be allowed to decide what to do.
The ACOG guideline on cesarean section states that, except for specific contraindications outlined in the article on p. 129, it is reasonable to encourage VBAC.2
Experiences drive patient preferences
OSF-St. Francis Medical Center in Peoria, IL, does eight to 10 VBACs a month with a nearly 100% success rate. The facility falls into the national average regarding C-sections approximately 25% overall.
An assortment of variables comes into play when a patient is considering what to do. "The woman who had a C-section to deliver her breech baby may be more willing to go for a TOL the second time around than a woman who had a C-section following a long and difficult TOL," explains Sue Sphar, RN, clinical associate for obstetric services at St. Francis. "That initial experience can leave a negative impact on a patient."
St. Francis is trying to do more VBACs. "The rule of thumb used to be, Once a C-section, always a C-section,’" says Sphar, "but that has changed. The rate of uterine rupture remains the same for both sets of patients those who have TOLs after a previous low transverse C-section and those who have second C-sections."
A uterine rupture following VBAC can result in a hysterectomy, but "they’re few and far between," says Sphar.
References
1. Roberts RG, Bell HS, Wall EM, et al. Trial of labor or repeated cesarean section: The woman’s choice. Arch Fam Med 1997; 6:120-125.
2. Gates PE. Think globally, act locally: An approach to implementation of clinical practice guidelines. Jt Comm J Qual Improv 1995; 21(2):71-84.
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