ACOG releases practice guidelines on vaginal delivery after previous cesarean birth – American College of Obstetricians and Gynecologists
The American College of Obstetricians and Gynecologists (ACOG) has issued a clinical practice guideline concerning vaginal delivery after previous cesarean section (VBAC). The purpose of the guideline is to present evidence regarding indications, safety, risks and benefits for a trial of labor based on a review of recent data. The algorithm shows the step-by-step approach for determining if VBAC is appropriate.
Studies were evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force: evidence obtained from at least one properly designed randomized controlled trial has been given the designation “I”; evidence obtained from well-designed controlled trials without randomization is identified as “II-1”; evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group, is designated “II-2”; 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) is identified as “II-3”; and opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees are designated as “III.”
Based on the highest level of evidence found in the data, the recommendations are graded according to the following categories: “A” – there is good evidence to support the recommendation; “B” – there is fair evidence to support the recommendation; and “C” – there is insufficient evidence to support the recommendation; however, the recommendation may be made on other grounds.
The bulleted items below represent the specific ACOG recommendations.
* Success rates for VBAC range from 60 to 80 percent (A:II-2).
* The benefits of a trial of labor outweigh the risks (A:II-2).
* In the absence of contraindications, a woman with one previous cesarean delivery with a lower transverse uterine incision is a candidate for VBAC and should be counseled and encouraged to undergo a trial of labor (A:II-2).
* A woman who has had two or more previous cesarean deliveries with lower transverse uterine incisions, who has no contraindications, and who wishes to attempt vaginal birth should not be discouraged from doing so (B:II-2)
* A previous classical uterine incision is a contraindication for VBAC (C:III).
* Epidural anesthesia is not a contraindication for VBAC (A:II-2). * Oxytocin use for induction or augmentation of labor is not contraindicated (B:II-3).
* Suspicion of macrosomia by itself in a nondiabetic patient should not disqualify a patient from a trial of labor (B:II-2).
* Available data are insufficient to determine the risks and benefits of VBAC for patients with multiple gestation, for patients with breech presentation, or for the use of prostaglandin gel (C:II-3, II-2).
* Vaginal birth after cesarean delivery should not be limited to large subspecialty hospital settings. Well-equipped basic and specialist hospitals with the capacity to respond to intrapartum emergencies are appropriate settings for VBAC (A:II-3).
The guidelines contain discussions of the recommendations. Copies may be purchased by contacting ACOG, 409 12th Street, S.W, Washington, DC 20024, telephone: 202-638-5577.
COPYRIGHT 1996 American Academy of Family Physicians
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