Vaginal birth after cesarean delivery: a group practice's approach to minimizing failed trial of labor.
Objective: Among women attempting a trial of labor (TOL) after a prior abdominal delivery, 60-80% accomplish a vaginal birth after cesarean (VBAC). McMahon and coworkers (N Engl J Med, 1996) have indicated that at a 60% success level for TOL, the remaining 40% incurred enough major complications that the scheduled repeat cesarean section group was less morbid overall. The same authors speculated that a success rate of 80% might be necessary for the TOL group's morbidity to be superior. We sought to review our group's patient selection experience during an interval when successful TOL consistently exceeded 80%.Methods: The study interval ranged from January 1995 through June 1997 and was limited to patients with one previous low transverse cesarean section. Rather than using administrative or charge-related diagnoses, we analyzed a departmental database that included each delivering physician's selection of one of four VBAC categories: successful VBAC, unsuccessful VBAC, patient declined trial of labor, or physician advised against trial of labor. All deliveries were at a single institution and were performed by one of seven obstetricians in a group practice.Results: During the study interval, 332 women provided a history of a single previous cesarean delivery. Of these 332, a total of 173 attempted a TOL and 150 of the 173 (87%) were successful. Fifty-eight of the 332 (18%) declined a trial of labor despite being assessed as excellent candidates, and 101 (30%) were advised against a TOL by their physician. Most common reasons for physicians discouraging labor included malpresentation, fetal macrosomia, and clinically small pelvis. Complications for the 23 of 173 (13%) experiencing a failed TOL included 1 asymptomatic partial separation of a uterine scar and 4 cases of puerperal fever; neither transfusion nor hysterectomy was required.Conclusions: This study demonstrates that in a population of women with one prior cesarean delivery, it is possible for a group practice to achieve a TOL success rate exceeding 80%. In our opinion the managing physician selecting out those patients least likely to attain a successful TOL contributes to a low failed TOL rate. We speculate that an analysis for best practice patterns within our group might reveal information of value for future practice guidelines.
Stedman
CM
Ochsner Clinic, Louisiana, New Orleans, USA
Scudder
SR
Joseph
GF