title: Evaluation of outcomes associated with trial of labor after cesarean delivery after a change in clinical practice guidelines in an academic hospital.
abstract: OBJECTIVE
  To evaluate maternal-neonatal morbidity for women undergoing trial of labor after cesarean (TOLAC) following clinical practice changes based upon ACOG's 2010 VBAC guideline.
  
  
  METHODS
  Four-year retrospective cohort analysis around implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 weeks and ≥1 prior cesarean. Maternal-neonatal outcomes pre- and post-guideline implementation were compared. Primary outcome was composite maternal morbidity (uterine rupture or dehiscence, hysterectomy, transfusion, thromboembolism, operative/delivery injury, chorioamnionitis/endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity.
  
  
  RESULTS
  Four hundred and fifty women underwent TOLAC before and 781 after guideline implementation. Post-guideline, there was a significant increase in age, body mass index, labor length, women with >1 cesarean, comorbid condition and induced labor. Composite maternal morbidity was significantly higher after the guideline (13.78% versus 18.82%, p = 0.02), possibly due to an increased rate of chorioamnionitis/endometritis, which was no longer significant after control for potential confounders in multivariable analysis. There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were unchanged (78.9% before versus 78.1% after, p = 0.75), however hospital VBAC rates increased after the guideline (26% versus 33%, p < 0.0001).
  
  
  CONCLUSIONS
  Adoption of ACOG's TOLAC practice changes can increase VBAC rates without increasing maternal-neonatal morbidity from TOLAC.
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Patricia
authors.initials: P
authors.lastname: Bellows
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Utsavi
authors.initials: U
authors.lastname: Shah
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Lauren
authors.initials: L
authors.lastname: Hawley
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Drexler
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Manisha
authors.initials: M
authors.lastname: Gandhi
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Haleh
authors.initials: H
authors.lastname: Sangi-Haghpeykar
authors.affiliation: a Department of Obstetrics and Gynecology , Baylor College of Medicine , Houston , TX , USA.
authors.forename: Christina
authors.initials: C
authors.lastname: Davidson
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D018570:Risk Assessment; D014219:Trial of Labor; D016064:Vaginal Birth after Cesarean / Q000009:adverse effects*; D055815:Young Adult
keywords: ACOG guidelines; TOLAC; VBAC; academic hospital; clinical practice change; maternal and neonatal morbidity