Evidence Based: Vaginal Birth After Cesarean: First Research

First Research
Evidence Based: Vaginal birth after cesarean

They synthesize the published literature on vaginal birth after cesarean (VBAC). Specifically, to
review the trends and incidence of VBAC, maternal benefits and harms, infant benefits and harms,
relevant factors influencing each, and the directions for future research.
Specific inclusion and exclusion criteria were developed to determine study eligibility. The target
population includes healthy women of reproductive age, with a singleton gestation, in the U.S. with a
prior cesarean who are eligible for a trial of labor (TOL) or elective repeat cesarean delivery (ERCD). All
eligible studies were quality rated and data were extracted from good or fair quality studies, entered
into tables, summarized descriptively and, when appropriate, pooled for analysis. The primary focus of
the report was term pregnancies. However, due to a small number of studies on term pregnancies,
general population studies including all gestational ages (GA) were included in appropriate areas.
They identified 3,134 citations and reviewed 963 papers for inclusion, of which 203 papers met
inclusion and were quality rated. Studies of maternal and infant outcomes reported data based upon
actual rather than intended router of delivery. The range for TOL and VBAC rates was large (28-82
percent and 49-87 percent, respectively) with the highest rates being reported in studies outside of the
U.S. Predictors of women having a TOL were having a prior vaginal delivery and settings of higher-level
care (e.g., tertiary care centers). TOL rates in U.S. studies declined in studies initiated after 1996 from 63
to 47 percent, but the VBAC rate remained unimproved. Hispanic and African American women were
less likely than their white counterparts to have a vaginal delivery. Overall rates of maternal harms were
low for both TOL and ERCD. While rare for both TOL and ERCD, maternal mortality was significantly
increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal
hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate
of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly
increased with TOL (4.7/1,000 versus 0.3/1,000 ERCD). Six percent of uterine ruptures were associated
with perinatal death. No models have been able to accurately predict women who are more likely to
deliver by VBAC or to rupture. Women with one prior cesarean delivery and previa had a statistically
significant increased risk of adverse events compared with previa patients without a prior cesarean
delivery; blood transfusion (15 versus 32.2 percent), hysterectomy (0.7 to 4 percent versus 10 percent),
and composite maternal morbidity (15 versus 23-30 percent). Perinatal mortality was significantly
increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD. Insufficient data were found on
nonmedical factors such as medical liability, economics, hospital staffing, structure and setting, which all
appear to be important drivers for VBAC.
1. My insight about this research:
Each year childbearing women have cesarean deliveries, and the population continues to
increase and VBAC is a reasonable and safe choice for the majority of women with prior
cesarean.
Second Research
Implementation of Evidence-Based Cesarean Section (CS) Technique
Despite evidence supporting specific CS operative techniques, usage is poor. We aimed to
observe the effect of a QI initiative on evidence-based operative techniques uptake and its impact on
postoperative pain, operative time and estimated blood loss (EBL).
Literature review identified blunt fascial dissection, lack of bladder flap, passive placental
delivery, no peritoneal closure, and sutured skin closure as best practice operative techniques. The QI
initiative identifying these practices was disseminated through written communication and large group
discussion, including both faculty and trainees. Chart review abstracted demographic data, adherence to
evidence-based techniques, operative time, post-operative pain scores at 48 hours, and pre- and post-
operative hemoglobin for the 6 months before and after the QI initiative.
Their results 509 cases met inclusion criteria; 256 prior to QI and 203 following. After QI, blunt
facial dissection increased (13.4 to 41.6%, p=0.00), bladder flap creation decreased (25.4 to 12.3%,
p=0.0002), manual placental extraction decreased (75.6 to 48.2%, p=0.00), peritoneal closure decreased
(46.5 to 32.8%, p=0.0016), and subcuticular skin closure increased (77 to 89.7%, p=0.0001) (all
controlled for baseline differences between groups). Operative time, postoperative pain measures, and
EBL did not change after the QI initiative. Controlling for all other factors, blunt fascial dissection was
associated with decreased operative time (p=0.00) and increased post-op pain at 48 hours (p=0.01).
2. My reflection about this research:
The recommendations from a QI initiative resulted in increased uptake of best practice operative
techniques, with varying effects on measured operative outcomes. There project should demonstrate
the need for continue efforts in standardization of operative technique.

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First Research

Evidence Based: Vaginal birth after cesarean

1. My insight about this research:

2. My reflection about this research:

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