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 Reining in Repeat Cesarean Deliveries
Lowering the U.S. cesarean delivery rate requires a multifaceted approach.
If the U.S. cesarean delivery rate were to keep rising at its current pace, that rate would exceed 50% by 2020. Strategies to curb this trend must focus not only on limiting primary cesarean rates, but also on devising rational strategies for lowering rates of repeat cesarean deliveries. Dr. James Scott, Editor-in-Chief of Obstetrics & Gynecology, has drawn together several approaches in an encapsulation of evidence-based professional recommendations.
The NIH Consensus Development Conference on Vaginal Birth after Cesarean (VBAC) was convened in 2010 to address declining VBAC rates. Key points included the following:
• Some women are denied access to trials of labor after cesarean (TOLAC).
• Risks associated with TOLAC and VBAC are low.
• Immediate access to cesarean delivery is not applied as a standard for other potential obstetric emergencies.
• Professional medical societies should reexamine their policies to improve TOLAC access.
Following the NIH conference, the American College of Obstetricians and Gynecologists released new guidelines for VBAC that included the following noteworthy updates (JW Womens Health Aug 5 2010):
• Restrictive policies should not result in repeat cesareans that are not wanted by patients.
• With the patient's informed consent, TOLAC can be considered, even if immediate access to cesarean delivery cannot be assured.
• TOLAC can be considered in women with two prior cesarean deliveries.
Given that most U.S. women deliver in community medical centers that might not have in-house obstetricians and anesthesiologists around the clock, planning for VBAC in these institutions warrants special attention. Providing safe access to TOLAC might require training with obstetric simulation and creation of management algorithms tailored to particular practice settings.
In addition to changes at the systems level, antepartum and intrapartum management of individual patients with prior cesarean deliveries is critical to VBAC policy. To this end:
• Personalized estimates of VBAC success that account for several maternal factors and clinical settings should be developed.
• Clinicians should use oxytocin judiciously and avoid using misoprostol altogether.
• Continuous electronic fetal monitoring is recommended.
• The possibility of uterine rupture must be considered in the face of fetal heart rate abnormalities, abdominal pain, vaginal bleeding, or loss of fetal station.
Comment: The public health consequences of the high cesarean rate are enormous. Dr. Scott spells out important "common-sense" patient- and systems-level strides to improve access to and success of VBAC. However, as an editorialist notes, healthcare providers represent one leg of a triad that contributes to U.S. cesarean delivery rates. Aggressive measures to dispel the specter of litigation and to diminish providers' financial and lifestyle incentives to schedule repeat cesareans also are critical to any successful solution.
— Allison Bryant, MD, MPH
Published in Journal Watch Women's Health August 4, 2011
Citation(s):Scott JR. Vaginal birth after cesarean delivery: A common-sense approach. Obstet Gynecol 2011 Aug; 118:342.
Medline abstract (Free)
Queenan JT. How to stop the relentless rise in cesarean deliveries. Obstet Gynecol 2011 Aug; 118:199.
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