NIH Consensus Development Conference on
Vaginal Birth After Cesarean:
New Insights
March 8–10, 2010
Bethesda, Maryland
Conference Home
Online Registration
Location & Logistics
Can't Attend?
Background
Sponsors
Agenda
Background
Vaginal birth after cesarean (VBAC) is the delivery of a baby through the vagina after a previous cesarean delivery. For most of the 20th century, once a woman had undergone a cesarean (the delivery of a baby through an incision made in the abdominal wall and uterus), many clinicians believed that all of her future pregnancies required delivery by cesarean as well. However, 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 try to labor and deliver vaginally rather than plan a cesarean delivery was thus offered and exercised more often from the 1980s through the early 1990s. Since 1996, however, VBAC rates in the United States have consistently declined, while cesarean delivery rates have been steadily rising.
The exact causes of these shifts are not entirely understood. A frequently cited concern about VBAC is the possibility of uterine rupture during labor, because a cesarean delivery leaves a scar in the wall of the uterus at the incision site, which is weaker than other uterine tissue. Attempted VBAC may also be associated with endometritis (infection of the lining of the uterus), the need for a hysterectomy (removal of the uterus) or blood transfusion, as well as neurologic injury to the baby. However, repeat cesarean delivery may also carry a risk of bleeding or hysterectomy, uterine infections, and respiratory problems for the newborn. Having multiple cesarean deliveries may also be associated with placental problems in future pregnancies. Other important considerations that may influence decision making include the number of previous cesarean deliveries a woman has experienced, the surgical incision used during previous cesarean delivery, the reason for the previous surgical delivery, her age, how far the pregnancy is along relative to her due date, and the size and position of her baby. Given the complexity of this issue, a thorough examination of the relative balance of benefits and harms to mother and baby will be of immediate utility to practitioners and pregnant mothers in deciding upon a planned mode of delivery.
A number of non-clinical factors are involved in this decision as well, and may be influencing the decline in VBAC rates. Some individual practitioners and hospitals in the U.S. have decreased or eliminated their use of VBAC. Professional society guidelines may influence utilization rates because some medical centers do not offer the recommended supporting services for a trial of labor after cesarean (e.g., immediate availability of a surgeon who can perform a cesarean delivery and on-site anesthesiologists). Information related to complications of an unsuccessful attempt at VBAC, medico-legal concerns, personal preferences of patients and clinicians, and insurance policies and economic considerations may all play a role in changing practice patterns. Improved understanding of the clinical risks and benefits, and how they interact with legal, ethical, and economic forces to shape provider and patient choices about VBAC may have important implications for health services planning.
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 the NIH will convene a Consensus Development Conference from March 8–10, 2010. The conference will address the following key questions:
- What are the rates and patterns of utilization of trial of labor after prior cesarean, vaginal birth after cesarean, and repeat cesarean delivery in the United States?
- Among women who attempt a trial of labor after prior cesarean, what is the vaginal delivery rate and the factors that influence it?
- 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?
- 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?
- What are the nonmedical factors that influence the patterns and utilization of trial of labor after prior cesarean?
- What are the critical gaps in the evidence for decision-making, and what are the priority investigations needed to address these gaps?
Invited experts will present information pertinent to the posed questions and a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality (AHRQ) will be summarized. Conference attendees will have ample time to ask questions and provide comments during open discussion periods. After weighing the scientific evidence, an unbiased, independent panel will prepare and present a consensus statement addressing the key conference questions.
Eunice Kennedy Shriver National Institute of Child Health and Human Development
Office of Medical Applications of Research
of the National Institutes of Health
Co-sponsor
Office of Research on Women's Health
Monday, March 8, 2010
| 8:30 a.m. | Introduction and Opening Remarks TBA Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health |
| 8:40 a.m. | Charge to the Panel Jennifer Miller Croswell, M.D., M.P.H. Acting Director Office of Medical Applications of Research Office of the Director National Institutes of Health |
| 8:50 a.m. | Conference Overview and Panel Activities F. Gary Cunningham, M.D. Panel and Conference Chairperson Beatrice and Miguel Elias Distinguished Chair in Obstetrics and Gynecology Professor, Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas |
| 9:00 a.m. | Overview of the Topic Caroline Signore, M.D., M.P.H. Medical Officer Pregnancy and Perinatology Branch Center for Developmental Biology and Perinatal Medicine Eunice Kennedy Shriver National Institute of Child Health and Human Development |
| I. | What Are the Rates and Patterns of Utilization of Trial of Labor After Prior Cesarean, Vaginal Birth After Cesarean, and Repeat Cesarean Delivery in the United States? |
| 9:15 a.m. | Trends and Patterns of VBAC Availability in the United States Kimberly D. Gregory, M.D., M.P.H. Vice Chair, Womens Healthcare Quality and Performance Improvement Department of Obstetrics and Gynecology Cedars Sinai Medical Center |
| II. | Among Women Who Attempt a Trial of Labor After Prior Cesarean, What Is the Vaginal Delivery Rate and the Factors That Influence It? |
| 9:35 a.m. | Evidence-Based Practice Center Presentation I: Trial of Labor, Vaginal Delivery Rates, and Relevant Factors TBA |
| 9:55 a.m. | Success Rates and Predicting Successful VBAC William A. Grobman, M.D., M.B.A. Associate Professor Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology Feinberg School of Medicine Northwestern University |
| 10:15 a.m. | Discussion |
| III. | 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? |
| 10:45 a.m. | Evidence-Based Practice Center Presentation II: Maternal Benefits and Harms, and Relevant Factors TBA |
| 11:05 a.m. | Delivery After Previous Cesarean: Short Term Maternal Outcomes Mona T. Lydon-Rochelle, Ph.D., M.P.H., C.N.M. Associate Professor/Perinatal Epidemiologist National Perinatal Epidemiology Centre Anu Research Centre Department of Obstetrics and Gynaecology and Department of Epidemiology & Public Health University College Cork |
| 11:25 a.m. | Discussion |
| 11:45 a.m. | Lunch Panel Executive Session |
| 12:45 p.m. | Delivery After Previous Cesarean: Long Term Maternal Outcomes Robert M. Silver, M.D. Professor Chief, Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology University of Utah Health Sciences Center |
| 1:05 p.m. | Predicting Uterine Rupture Mark B. Landon, M.D. Professor Director, Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology Ohio State University College of Medicine |
| 1:25 p.m. | Discussion |
| IV. | 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? |
| 1:45 p.m. | Evidence-Based Practice Center Presentation III: Infant Benefits and Harms, and Relevant Factors TBA |
| 2:05 p.m. | Delivery After Previous Cesarean: Short Term Infant Outcomes Lucky Jain, M.D., M.B.A. Richard W. Blumberg Professor and Executive Vice Chairman Department of Pediatrics Emory University School of Medicine |
| 2:25 p.m. | Delivery After Previous Cesarean: Long Term Infant Outcomes T. Michael OShea, M.D., M.P.H. Professor Chief, Division of Neonatology Department of Pediatrics Baptist Medical Center Wake Forest University |
| 2:45 p.m. | Synthesis: Weighing Risks to Mother and Infant George A. Macones, M.D., M.S.C.E. Elaine and Mitchell Yanow Professor and Chairman Department of Obstetrics and Gynecology Washington University School of Medicine |
| 3:05 p.m. | Discussion |
| V. | What Are the Non-Medical Factors That Influence the Patterns and Utilization of Trial of Labor After Prior Cesarean? |
| 3:45 p.m. | Trial of Labor versus Elective Repeat Cesarean: An Administrator's Perspective Michael L. Socol, M.D. Thomas J. Watkins Memorial Professor and Vice Chair Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine Feinberg School of Medicine Northwestern University |
| 4:15 p.m. | Evaluating Professional Society Guidelines on VBAC Emmanuel Bujold, M.D., F.R.C.S.C. Department of Obstetrics and Gynaecology Faculté de Médecine Université Laval |
| 4:35 p.m. | Discussion |
| 5:00 p.m. | Adjournment |
Tuesday, March 9, 2010
| V. | What Are the Non-Medical Factors That Influence the Patterns And Utilization of Trial of Labor After Prior Cesarean? (Continued) |
| 8:30 a.m. | Trial of Labor versus Elective Repeat Cesarean: The Impact of Anesthesiologist Availability David J. Birnbach, M.D., M.P.H. Professor Department of Anesthesiology and Obstetrics and Gynecology Associate Dean and Director, Jackson Memorial Hospital Center for Patient Safety Miller School of Medicine University of Miami |
| 8:50 a.m. | Exploring the Immediately Available Physician Standard Howard Minkoff, M.D. Professor Department of Obstetrics and Gynecology SUNY-Brooklyn; Maimonides Medical Center |
| 9:10 a.m. | Understanding Risk, Patient and Provider Preferences, and Obstetric Decision Making Miriam Kuppermann, Ph.D., M.P.H. Associate Professor Departments of Obstetrics, Gynecology, and Reproductive Sciences and Epidemiology and Biostatistics University of California San Francisco |
| 9:30 a.m. | Discussion |
| 10:00a.m. | The Medical Ethics of VBAC Anne D. Lyerly, M.D. Associate Professor Department of Obstetrics and Gynecology Faculty Associate, Center for the Study of Medical Ethics and Humanities Duke University |
| 10:20 a.m. | Mothers' Stories Rita Rubin Medical Reporter USA Today |
| 10:40 a.m. | Walking the Line: The Obstetric Provider Experience Chet Edward Wells, M.D. Professor Department of Obstetrics and Gynecology University of Texas Southwestern Medical Center at Dallas |
| 11:00 a.m. | Discussion |
| 11:30 a.m. | Adjournment |
Wednesday, March 10, 2010
| 9:00 a.m. | Presentation of the Draft Consensus Statement |
| 9:30 a.m. | Public Discussion |
| 11:00 a.m. | Adjournment Panel Meets in Executive Session |
| 2:00 p.m. | Press Telebriefing |
To top
Contact Consensus Program | Privacy Notice | Disclaimer | Accessibility | Contact NIH
