ACOG Updates Recommendations on Vaginal Birth After Previous Cesarean Delivery CARRIE ARMSTRONG

Am Fam Physician. 2011 Jan 15;83(2):215-217.

Related Editorial

Guideline source: American College of Obstetricians and Gynecologists(ACOG) Literature search described? Yes Evidence rating system used? Yes Published source: Obstetrics & Gynecology, August 2010 Available at: http://journals.lww.com/greenjournal/toc/2010/08000 The rate of cesarean delivery has increased dramatically in the United States over the past four decades, perpetuated somewhat by the dictum once a cesarean, always a cesarean. However, evidence has shown that many women who have had a cesarean delivery can safely deliver vaginally in subsequent pregnancies. Advantages of this approach include avoidance of major surgery, lower risk of hemorrhage and infection, and shorter recovery periods. Between 1985 and 1996, rates of vaginal birth after previous cesarean delivery (VBAC) increased steadily. Since the mid-1990s, however, medicolegal issues and concerns about the risk of uterine rupture have contributed to a reversal in this trend.

Although a trial of labor after previous cesarean delivery (TOLAC) is appropriate in select women, several factors increase the likelihood of complications. The risks associated with TOLAC are the same as those associated with elective repeat cesarean delivery: maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. Because most maternal morbidity during TOLAC occurs when repeat cesarean delivery becomes necessary, VBAC is associated with fewer complications than elective repeat cesarean delivery, and failed TOLAC is associated with more complications. The outcome of TOLAC that most significantly increases the risk of maternal and neonatal morbidity is uterine rupture or dehiscence. The incidence of uterine rupture varies, but the risk is higher in women with a history of hysterotomies. The location of the prior uterine incision influences risk.

Determining Candidates for TOLAC

Most studies of women attempting TOLAC have shown a 60 to 80 percent probability of VBAC. Individual demographic and obstetric factors that affect a woman's probability of successful TOLAC are listed in Table 1. Women in whom the balance of risks and the chances of successful VBAC are acceptable to the patient and the physician are good candidates for planned TOLAC. Decisions about TOLAC should take into account the possibility of future pregnancies, because delivery decisions made in the first pregnancy after a cesarean delivery typically affect plans in subsequent pregnancies. Because of the risks associated with TOLAC, it should be attempted in facilities with staff immediately available to provide emergency care.

TABLE 1. Factors Associated with Successful Trial of Labor After Previous Cesarean Delivery Increased probability of success Previous vaginal birth Spontaneous labor Decreased probability of success Gestational age greater than 40 weeks Increased maternal age Increased neonatal birth weight Maternal obesity Nonwhite ethnicity Preeclampsia Recurrent indication for cesarean delivery Short interpregnancy interval Adapted with permission from American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115. Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2):452.

PRIOR DELIVERIES Most women who have had one previous cesarean delivery with a low transverse incision should be counseled about VBAC and offered TOLAC. Women who had a low vertical incision seem to have similar

rates of successful VBAC, and may attempt TOLAC. Women at high risk of complications (e.g., those with a previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC.

The safety of VBAC has been questioned in women who had a previous cesarean delivery with an unknown incision type. However, two case series reported similar rates of successful VBAC between women with unknown previous incision types and those with previous low transverse incisions. No significant association was noted between unknown incision types and rates of uterine rupture. Therefore, TOLAC is not contraindicated in women who have had one previous cesarean delivery with an unknown incision type, unless there is high clinical suspicion of a previous classical incision.

It is unclear whether the risk of uterine rupture is lower in women attempting TOLAC who have had only one previous cesarean delivery compared with those who have had more. The chances of achieving VBAC are similar between these groups of women. Therefore, it is reasonable to consider TOLAC in women who have had two previous low transverse cesarean deliveries, and to counsel them based on other factors that affect their chances of successful VBAC. Data on the risk in women who have had more than two previous cesarean deliveries are limited.

MACROSOMIA Women attempting TOLAC with a macrosomic fetus (greater than 4,000 to 4,500 g [8 lb, 13 oz to 9 lb, 15 oz]) have a lower likelihood of successful VBAC than those who have a nonmacrosomic fetus. Women who have had a previous cesarean delivery because of dystocia also have a lower likelihood of VBAC if the weight of the current fetus is greater than that of the index pregnancy. There is limited evidence that the risk of uterine rupture is greater in women who have not had a previous vaginal delivery and who are attempting TOLAC with a macrosomic fetus. It is important to note, however, that these data are based on actualnot predictedbirth weight, thus limiting their applicability when making delivery decisions antenatally. Although previous and predicted birth weights should be considered when making delivery decisions, suspected macrosomia alone is not a contraindication for TOLAC.

GESTATION BEYOND 40 WEEKS Rates of VBAC are consistently lower in women who attempt TOLAC after 40 weeks' gestation. However, most studies have not shown that the risk of uterine rupture is increased in these women. Although the chances of successful VBAC are lower, gestation beyond 40 weeks is not a contraindication for TOLAC.

TWIN GESTATION Women with twin gestations who attempt VBAC have similar outcomes to women with singleton gestations. Therefore, TOLAC can be considered in women who have had one previous cesarean delivery with a low transverse incision and who have no contraindications for twin vaginal delivery.

Labor Management Several studies have noted an increased risk of uterine rupture after labor induction in women attempting TOLAC. Although labor can be induced for maternal or fetal indications in women attempting TOLAC, physicians should counsel the patient that it increases risk of uterine rupture and decreases the possibility of successful VBAC.

Studies of the effects of prostaglandins on uterine rupture in women who have had a previous cesarean delivery have had inconsistent results. One large study found an increased risk of uterine rupture, whereas a second study found no increased risk, and a third found no increased risk when prostaglandins were used alone (with no subsequent oxytocin [Pitocin]). Studies of specific prostaglandins are limited, but generally indicate that the risk of uterine rupture may vary among agents. Evidence from small studies shows that the use of misoprostol (Cytotec) increases the risk of uterine rupture in women who have had previous cesarean deliveries. Therefore, this agent should not be used for third trimester cervical ripening or labor induction in women who have had a previous cesarean delivery or major uterine surgery.

Limited data suggest that external cephalic version for breech presentation is not contraindicated in women with prior uterine incisions if the risk of adverse maternal and neonatal outcomes is low. The chances of successful external version are similar in women with and without a previous cesarean delivery.

Epidural analgesia may be used during TOLAC, and adequate pain relief may encourage more women to attempt TOLAC. Effective regional analgesia should not be expected to mask signs of uterine rupture.

EDITOR'S NOTE: In early 2010, the National Institutes of Health (NIH) held a consensus conference focusing on short- and long-term maternal and neonatal outcomes of VBAC versus elective repeat cesarean delivery.1 Several speakers emphasized that the overall risk of perinatal morbidity and

mortality associated with TOLAC is similar to that of any nulliparous woman in labor.2 A recent systematic review conducted for the NIH found that VBAC is a reasonable option in most women, and that adverse outcomes are rare.3

However, women who wish to attempt VBAC face several obstacles in gaining access to physicians and facilities that offer TOLAC. Many hospitals no longer allow VBAC because they are not able to provide immediate access to surgeons and anesthesiologists, and some insurance carriers prohibit physicians from performing the procedure. The NIH conference called on ACOG and the American Society of Anesthesiologists to reconsider the immediate availability stipulation, and for hospitals, maternity care providers, health care and professional liability insurers, consumers, and policymakers to collaborate on developing integrated services that could mitigate or eliminate current barriers to TOLAC.1c.a.

REFERENCES 1. National Institutes of Health Consensus Development Conference statement: vaginal birth after cesarean: new insights. March 810, 2010. Obstet Gynecol. 2010;115(6):12791295. 2. Scott JR. Solving the vaginal birth after cesarean dilemma [editorial]. Obstet Gynecol. 2010;115(6):11121113. 3. Guise JM, Denman MA, Emeis C, et al. Vaginal birth after cesarean: new insights on maternal and neonatal outcomes. Obstet Gynecol. 2010;115(6):12671278. Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP

http://www.aafp.org/afp/2011/0115/p214.html

Guideline Title Vaginal birth after previous cesarean delivery. Bibliographic Source(s) American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Aug. 14 p.(ACOG practice bulletin; no. 115). [136 references] Guideline Status This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Jul. 10 p. (ACOG practice bulletin; no. 54). [105 references]

Jump ToGuideline ClassificationRelated Content Scope Methodology Recommendations Evidence Supporting the Recommendations Benefits/Harms of Implementing the Guideline Recommendations Contraindications -

Qualifying Statements Implementation of the Guideline Institute of Medicine (IOM) National Healthcare Quality Report Categories Identifying Information and Availability Disclaimer Back to top Scope Disease/Condition(s) Vaginal birth after previous cesarean delivery

Guideline Category Counseling Management Prevention Risk Assessment Clinical Specialty Family Practice Obstetrics and Gynecology Intended Users Advanced Practice Nurses Nurses

Physician Assistants Physicians Guideline Objective(s) To aid practitioners in making decisions about appropriate obstetric and gynecologic care To review the current risks and benefits of a trial of labor after previous cesarean delivery (TOLAC) in various clinical situations and provide practical guidelines for managing and counseling patients who will give birth after a previous cesarean delivery Target Population Pregnant women who have had a previous cesarean delivery

Interventions and Practices Considered Patient's obstetric history Patient counseling regarding benefits and risks of vaginal birth after cesarean delivery (VBAC), trial of labor after previous cesarean deliver (TOLAC), and elective repeat cesarean delivery Labor management including external cephalic version for breech presentation, use of epidural analgesia if desired by the patient, induction of labor for maternal or fetal indications, and delivery at facilities capable of emergency delivery Note: Misoprostol for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery was considered but not recommended.

Major Outcomes Considered Success rate for trials of labor after previous cesarean delivery (TOLAC) Rates of maternal complications, including uterine rupture or dehiscence, hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death Length of recovery period Rates of neonatal morbidity Back to top Methodology

Methods Used to Collect/Select the Evidence Hand-searches of Published Literature (Primary Sources) Hand-searches of Published Literature (Secondary Sources) Searches of Electronic Databases Description of Methods Used to Collect/Select the Evidence The MEDLINE database, the Cochrane Library, and American College of Obstetricians and Gynecologists' (ACOG's) own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and February 2010. The search was restricted to articles published in the English language. Priority was given to the articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document.

Guidelines published by organizations or institutions such as the National Institutes of Health and ACOG were reviewed, and additional studies were located by reviewing bibliographies of identified articles. When reliable research was not available, expert opinions from obstetriciangynecologists were used.

Number of Source Documents Not stated

Methods Used to Assess the Quality and Strength of the Evidence Weighting According to a Rating Scheme (Scheme Given) Rating Scheme for the Strength of the Evidence Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force.

I Evidence obtained from at least one properly designed randomized controlled trial.

II-1 Evidence obtained from well-designed controlled trials without randomization.

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Methods Used to Analyze the Evidence Review of Published Meta-Analyses Systematic Review Description of the Methods Used to Analyze the Evidence Not stated

Methods Used to Formulate the Recommendations Expert Consensus Description of Methods Used to Formulate the Recommendations Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetriciangynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Rating Scheme for the Strength of the Recommendations Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A - Recommendations are based on good and consistent scientific evidence.

Level B - Recommendations are based on limited or inconsistent scientific evidence.

Level C - Recommendations are based primarily on consensus and expert opinion.

Cost Analysis A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation Internal Peer Review Description of Method of Guideline Validation Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists Executive Board.

Back to top Recommendations Major Recommendations The grades of evidence (IIII) and levels of recommendations (AC) are defined at the end of "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

Most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about vaginal birth after cesarean delivery (VBAC) and offered a trial of labor after previous cesarean delivery (TOLAC). Epidural anesthesia for labor may be used as part of TOLAC.

Misoprostol should not be used for third semester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery. The following recommendations are based on limited or inconsistent scientific evidence (Level B):

Women with two previous low transverse cesarean deliveries may be considered candidates for TOLAC. Women with one previous cesarean delivery with a low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC. External cephalic version for breech presentation is not contraindicated in women with a prior low transverse uterine incision who are at low risk for adverse maternal or neonatal outcomes from external cephalic version and TOLAC. Those at high risk for complications (e.g., those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated (e.g., those with placenta previa) are not generally candidates for planned TOLAC. Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC. TOLAC is not contraindicated for women with previous cesarean delivery with an unknown uterine scar type unless there is a high clinical suspicion of a previous classical uterine incision. The following recommendations are based primarily on consensus and expert opinion (Level C):

A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries. Because of the risks associated with TOLAC and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care. When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital's resources and availability of obstetric, pediatric, anesthetic, and operating room staffs. Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk; however, patients should be clearly informed of such potential increase in risk and management alternatives. After counseling, the ultimate decision to undergo TOLAC or a repeat cesarean delivery should be made by the patient in consultation with her health care provider. The potential risks and benefits of both TOLAC and elective repeat cesarean delivery should be discussed. Documentation of counseling and the management plan should be included in the medical record. Definitions:

Level of Recommendations

Level A - The recommendation is based on good and consistent scientific evidence.

Level B - The recommendation is based on limited or inconsistent scientific evidence.

Level C - The recommendation is based primarily on consensus and expert opinion.

Grade of Evidence

I Evidence obtained from at least one properly designed randomized controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

Clinical Algorithm(s) None provided

Back to top

Evidence Supporting the Recommendations Type of Evidence Supporting the Recommendations The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Back to top Benefits/Harms of Implementing the Guideline Recommendations Potential Benefits Women who achieve vaginal birth after cesarean delivery (VBAC) avoid major abdominal surgery, resulting in lower rates of hemorrhage, infection, and a shorter recovery period compared with elective repeat cesarean delivery. For those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries such as hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta. Potential Harms The risks of either trial of labor after cesarean delivery (TOLAC) or elective repeat cesarean delivery include maternal hemorrhage, infection, operative injury, thromboembolism, hysterectomy, and death. A failed TOLAC is associated with more complications than elective repeat cesarean delivery. Uterine rupture or dehiscence is the outcome associated with TOLAC that most significantly increases the chance of additional maternal and neonatal morbidity. Neonatal morbidity is higher in the setting of a failed TOLAC than in a vaginal birth after cesarean delivery (VBAC). Back to top Contraindications Contraindications Contraindications for Vaginal Birth after Cesarean Delivery

Previous classical or T-shaped incision or extensive transfundal uterine surgery Previous uterine rupture

Women in whom vaginal delivery is otherwise contraindicated (e.g., those with placenta previa) Back to top Qualifying Statements Qualifying Statements These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice. There are currently no randomized trials comparing maternal or neonatal outcomes between women undertaking a trial of labor after cesarean delivery (TOLAC) and those undergoing repeat cesarean delivery. Back to top Implementation of the Guideline Description of Implementation Strategy An implementation strategy was not provided.

Implementation Tools Audit Criteria/Indicators Foreign Language Translations Patient Resources For information about availability, see the Availability of Companion Documents and Patient Resources fields below. Back to top Institute of Medicine (IOM) National Healthcare Quality Report Categories IOM Care Need Staying Healthy IOM Domain Effectiveness

Patient-centeredness Safety Back to top Identifying Information and Availability Bibliographic Source(s) American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2010 Aug. 14 p.(ACOG practice bulletin; no. 115). [136 references] Adaptation Not applicable: The guideline was not adapted from another source.

Date Released 1999 Jun (revised 2010 Aug) Guideline Developer(s) American College of Obstetricians and Gynecologists - Medical Specialty Society Source(s) of Funding American College of Obstetricians and Gynecologists (ACOG)

Guideline Committee American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins Obstetrics

Composition of Group That Authored the Guideline American College of Obstetricians and Gynecologists (ACOG) committees are created or abolished and their overall function defined by the Executive Board. Appointments are made for one year, with the understanding that such appointment may be continued for a total of three years. The majority of committee members are Fellows, but Junior Fellows also are eligible for appointment. Some committees may have representatives from other organizations when this is particularly appropriate to committee activities. The president elect appoints committee members annually.

Financial Disclosures/Conflicts of Interest Not stated

Guideline Status This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Vaginal birth after previous cesarean delivery. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Jul. 10 p. (ACOG practice bulletin; no. 54). [105 references]

Guideline Availability Electronic copies: Not available at this time.

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site .

Availability of Companion Documents Proposed performance measures are included in the original guideline document.

Patient Resources The following is available:

Vaginal birth after cesarean delivery. Atlanta (GA): American College of Obstetricians and Gynecologists (ACOG); 2009. Available from the ACOG Web site . Copies are also available in Spanish .

Print copies: Available for purchase from the American College of Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 933104, Atlanta, GA 31193-3104; telephone, 800-762-2264, ext. 192; e-mail: sales@acog.org. The ACOG Bookstore is available online at the ACOG Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status This NGC summary was completed by ECRI on January 14, 2004. This NGC summary was updated by ECRI on February 9, 2005. The information was reaffirmed by the guideline developer in 2009 and updated by ECRI Institute on February 9, 2010. This NGC summary was updated by ECRI Institute on September 17, 2010.

Copyright Statement This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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