Recent Trends In Vaginal Births After Cesarean Delivery United States 2016 2018

Vaginal birth after cesarean (VBAC) describes vaginal delivery by a woman who has had a previous cesarean delivery. For most of the 20th century, once a woman had undergone a cesarean delivery, clinicians believed that her future pregnancies required cesarean delivery. Studies from the 1960s suggested that this practice may not always be necessary. In 1980, a National Institutes of Health (NIH) Consensus Development Conference Panel questioned the necessity of routine repeat cesarean deliveries and outlined situations in which VBAC could be considered. The option for a woman with a previous cesarean delivery to have a trial of labor was offered and exercised more often in the 1980s through 1996. Since 1996, however, the number of VBACs has declined, contributing to the overall increase in cesarean delivery (Figure 1). Although we recognize that primary cesarean deliveries are the driving force behind the total cesarean delivery rates, the focus of this report is on trial of labor and repeat cesarean deliveries. A number of medical and nonmedical factors have contributed to this decline in the VBAC rate since the mid-1990s, although many of these factors are not well understood. A significant medical factor that is frequently cited as a reason to avoid trial of labor is concern about the possibility of uterine rupture-because an unsuccessful trial of labor, in which a woman undergoes a repeat cesarean delivery instead of a vaginal delivery, has a a higher rate of complications compared to VBAC or elective repeat cesarean delivery. Nonmedical factors include, among other things, restrictions on access to a trial of labor and the effect of the current medical-legal climate on relevant practice patterns. To advance understanding of these important issues, the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Office of Medical Applications of Research of NIH convened a Consensus Development Conference on March 8-10, 2010. The conference was grounded in the view that a thorough evaluation of the relevant research would help pregnant women and their maternity care providers when making decisions about the mode of delivery after a previous cesarean delivery. Improved understanding of the clinical risks and benefits and how they interact with nonmedical factors also may have important implications for informed decisionmaking and health services planning. The following key questions were addressed by the Consensus Development Conference: 1. What are the rates and patterns of utilization of trial of labor after prior cesarean delivery, vaginal birth after cesarean delivery, and repeat cesarean delivery in the United States? 2. Among women who attempt a trial of labor after prior cesarean delivery, what is the vaginal delivery rate and the factors that influence it? 3. What are the short-and long-term benefits and harms to the mother of attempting trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms? 4. What are the short- and long-term benefits and harms to the baby of maternal attempt at trial of labor after prior cesarean versus elective repeat cesarean delivery, and what factors influence benefits and harms? 5. What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean delivery? 6. What are the critical gaps in the evidence for decisionmaking, and what are the priority investigations needed to address these gaps?

This report provides a framework for comparing the harms and benefits of delivery options for women with prior cesarean delivery (CD). The information is designed to help consumers, providers, payers, and policymakers in decision making about repeat cesarean or trial of labor (TOL). In 2000, 22.9 percent of all births in the United States occurred by CD. This rate is the highest total CD rate reported since data collection began in 1989. The vaginal birth after cesarean (VBAC) rate, defined as the proportion of women with a prior CD who delivered vaginally, steadily increased from 1989 to 1996. As allowing TOL became more common, practice variation became a larger concern, e.g., expanding criteria for eligibility and medical induction, and for augmentation of labor. In parallel with this liberalization of criteria and management, highly publicized articles suggested that maternal and fetal risks were perceived to be increasing. Subsequently, the VBAC rate has decreased 27 percent from 1996 to 2000. Currently, a crisis in malpractice rates is decreasing the availability of maternity care providers and raising concerns that patients may have limited options, less access to care, and perhaps be at increased risk for complications. Two types of key questions were addressed. The first group (Questions 1- 7) compares the outcomes of a TOL and an ERCD: 1. What is the frequency of vaginal delivery in women who undergo a TOL (spontaneous onset, induced, and augmented) after prior low transverse cesarean or unknown scar? 2. How accurate are risk assessment tools for identifying patients who will have a vaginal delivery after a TOL? 3. What are the relative harms associated with a TOL (spontaneous onset, induced, and augmented) and repeat cesarean? 4. What is the incidence of uterine rupture, and are there methods for preventing major morbidity and mortality due to uterine rupture? 5. What are the health status and health-related quality of life for VBAC and repeat cesarean patients? 6. Regarding VBAC and repeat cesarean, what factors influence patient satisfaction/dissatisfaction with their childbirth experience? 7. How are economic outcomes related to VBAC, repeat CD, and their respective complications? The second group (Questions 8-10) address factors influencing the decision to have a TOL: 8. What individual factors influence route of delivery? 9. What factors influence a patient's decision making regarding VBAC or ERCD? 10. How do legislation, policy, guidelines, provider characteristics, insurance type, and access to care affect health outcomes for VBAC candidates?

This book draws on recently acquired knowledge to provide the reader with comprehensive, up-to-date information on the full range of obstetric complications that may be encountered during the third trimester of pregnancy and puerperium. For each complication, risk factors and clinical presentation are described and detailed guidance is provided on the appropriate treatment. The lucid text is complemented by a wealth of images, diagrams, flow charts, and drawings. The volume has been compiled in collaboration with a large group of gynecologists, obstetricians and internationally renowned scientists to provide an essential guide. Accordingly, the book is of interest to practitioners across the world, enabling them to deepen their knowledge and to refine their approach to complications in daily clinical practice.

The delivery of high quality and equitable care for both mothers and newborns is complex and requires efforts across many sectors. The United States spends more on childbirth than any other country in the world, yet outcomes are worse than other high-resource countries, and even worse for Black and Native American women. There are a variety of factors that influence childbirth, including social determinants such as income, educational levels, access to care, financing, transportation, structural racism and geographic variability in birth settings. It is important to reevaluate the United States' approach to maternal and newborn care through the lens of these factors across multiple disciplines. Birth Settings in America: Outcomes, Quality, Access, and Choice reviews and evaluates maternal and newborn care in the United States, the epidemiology of social and clinical risks in pregnancy and childbirth, birth settings research, and access to and choice of birth settings.

This book examines every aspect of anesthesia in patients undergoing cesarean section. Anesthetic and surgical techniques are clearly described, with detailed guidance on indications and contraindications and identification of potential complications. Practical information is provided on postoperative analgesia, postoperative course and nursing, the significance of cesarean section for breastfeeding, and the occurrence of long-term problems and chronic pain after cesarean section. Other topics to be addressed include the history and epidemiology of cesarean delivery, effects on the fetus and neonate, ethical issues, the humanization of childbirth, and maternal expectations and satisfaction. While many books are available on obstetric anesthesia, none is exclusively devoted to cesarean section although it is one of the most frequently performed surgeries. Anesthesia for Cesarean Section will be appreciated by all anesthesiologists and will be a useful source of information for obstetricians, gynecologists, midwives, nurses, medical students, and trainees.

This guide provides a full range of updated, evidence-based norms and standards that will enable health care providers to give high quality care during pregnancy, delivery and in the postpartum period, considering the needs of the mother and her newborn baby. All recommendations are for skilled attendants working at the primary level of health care, either at the facility or in the community. They apply to all women attending antenatal care, in delivery, postpartum or post abortion care, or who come for emergency care, and to all newborns at birth and during the first week of life (or later) for routine and emergency care. This guide is a guide for clinical decision-making. It facilitates the collection; analysis, classification and use of relevant information by suggesting key questions, essential observations and/or examinations, and recommending appropriate research-based interventions. It promotes the early detection of complications and the initiation of early and appropriate treatment, including time referral, if necessary. Correct use of this guide should help reduce high maternal and perinatal mortality and morbidity rates prevalent in many parts of the developing world, thereby making pregnancy and childbirth safer.

This up-to-date comprehensive and consolidated guideline on essential intrapartum care brings together new and existing WHO recommendations that when delivered as a package will ensure good-quality and evidence-based care irrespective of the setting or level of health care. The recommendations presented in this guideline are neither country nor region specific and acknowledge the variations that exist globally as to the level of available health services within and between countries. The guideline highlights the importance of woman-centred care to optimize the experience of labour and childbirth for women and their babies through a holistic human rights-based approach. It introduces a global model of intrapartum care which takes into account the complexity and diverse nature of prevailing models of care and contemporary practice. The recommendations in this guideline are intended to inform the development of relevant national- and local-level health policies and clinical protocols. Therefore the target audience includes national and local public health policy-makers implementers and managers of maternal and child health programmes health care facility managers nongovernmental organizations (NGOs) professional societies involved in the planning and management of maternal and child health services health care professionals (including nurses midwives general medical practitioners and obstetricians) and academic staff involved in training health care professionals.