Download PDF
Am J Perinatol 2023; 40(06): 575-581
DOI: 10.1055/a-1960-2797
SMFM Fellowship Series Article

Quality Initiative to Reduce Failed Trial of Labor after Cesarean Using Calculated VBAC Success Likelihood

Frank B. Williams 
1   Department of Obstetrics, Gynecology and Reproductive Services, University of Vermont, Burlington, Vermont
,
Hayley Pierce
1   Department of Obstetrics, Gynecology and Reproductive Services, University of Vermont, Burlington, Vermont
,
Carole A. McBride
1   Department of Obstetrics, Gynecology and Reproductive Services, University of Vermont, Burlington, Vermont
,
Justin DeAngelis
1   Department of Obstetrics, Gynecology and Reproductive Services, University of Vermont, Burlington, Vermont
,
Kelley McLean
1   Department of Obstetrics, Gynecology and Reproductive Services, University of Vermont, Burlington, Vermont
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Objective Vaginal birth after cesarean can reduce morbidity associated with multiple cesarean deliveries. Failed vaginal birth after cesarean is associated with increased maternal and neonatal morbidity. The Maternal-Fetal Medicine Units Vaginal Birth After Cesarean calculator is a validated tool to predict the likelihood of successful trial of labor after cesarean. Predicted likelihood < 60% has been associated with increased maternal and neonatal morbidity. We sought to determine if formal incorporation of calculated vaginal birth after cesarean likelihood into patient-centered counseling would reduce failed vaginal birth after cesarean.

Study Design This is a quality improvement intervention at a single tertiary-care academic medical center, in which standardized patient counseling was implemented, facilitated by an electronic medical record template featuring patient-specific likelihood of vaginal birth after cesarean success. Term singleton pregnancies with history of one to two cesareans were included; those with contraindication to labor were excluded. Historical controls (January 2016–December 2018, n = 693) were compared with a postimplementation cohort (January 2019–April 2020, n = 328). Primary outcome was failed vaginal birth after cesarean.

Results Fewer patients in the postintervention cohort had a history of an arrest disorder (PRE: 48%, 330/693 vs. POST: 40%, 130/326, p = 0.03); demographics were otherwise similar, including the proportion of patients with <60% likelihood of success (PRE: 39%, 267/693, vs. POST: 38%, 125/326). Following implementation, induction of labor in patients with a <60% likelihood of successful vaginal birth after cesarean decreased from 17% (45/267) to 5% (6/125, p < 0.01). The proportion of failed vaginal birth after cesarean decreased from 33% (107/329) to 22% (32/143, p = 0.04). Overall vaginal birth after cesarean rate did not change (PRE: 32%, 222/693, vs. POST: 34%, 111/326, p = 0.52).

Conclusion An intervention targeting provider counseling that included a validated vaginal birth after cesarean success likelihood was associated with decreased risk of failed trial of labor after cesarean without affecting overall vaginal birth after cesarean rate.

Key Points

  • Labored cesarean increases maternal morbidity.

  • Application of the Maternal-Fetal Medicine Units (MFMU) calculator to antenatal counseling decreased labored cesarean.

  • Application of the MFMU calculator to antenatal counseling did not decrease overall vaginal birth after cesarean rate.

Keywords

cesarean delivery - induction of labor - patient counseling - quality improvement - repeat cesarean - TOLAC - trial of labor - VBAC - vaginal birth after cesarean

Presented in Part

A portion of this work has been presented at the Society for Maternal Fetal Medicine's 41st Pregnancy Meeting, January 25–30, 2021, which took place virtually.


Supplementary Material



Publication History

Received: 06 April 2022

Accepted: 22 September 2022

Accepted Manuscript online:
13 October 2022

Article published online:
30 December 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Martin JA, Hamilton BE, Osterman MJK, Driscoll AK. Births: final data for 2019. Natl Vital Stat Rep 2021; 70 (02) 1-51
    PubMedGoogle Scholar
  • 2 ACOG Practice Bulletin No. ACOG Practice Bulletin No. 205: vaginal birth after cesarean delivery. Obstet Gynecol 2019; 133 (02) e110-e127
    CrossrefPubMedGoogle Scholar
  • 3 Osterman MJK. Recent trends in vaginal birth after cesarean delivery: United States, 2016-2018. NCHS Data Brief 2020; (359) 1-8
    PubMedGoogle Scholar
  • 4 McMahon MJ, Luther ER, Bowes Jr WA, Olshan AF. Comparison of a trial of labor with an elective second cesarean section. N Engl J Med 1996; 335 (10) 689-695
    CrossrefPubMedGoogle Scholar
  • 5 Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity. Am J Obstet Gynecol 2001; 184 (07) 1365-1371 , discussion 1371–1373
    CrossrefPubMedGoogle Scholar
  • 6 Landon MB, Hauth JC, Leveno KJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351 (25) 2581-2589
    CrossrefPubMedGoogle Scholar
  • 7 Macones GA, Peipert J, Nelson DB. et al. Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol 2005; 193 (05) 1656-1662
    CrossrefPubMedGoogle Scholar
  • 8 U.S. Department of Health and Human Services. Healthy people 2020: objective MICH-7.2. Accessed April 27, 2021 at: https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives
    PubMedGoogle Scholar
  • 9 Landon MB, Leindecker S, Spong CY. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. The MFMU Cesarean Registry: factors affecting the success of trial of labor after previous cesarean delivery. Am J Obstet Gynecol 2005; 193 (3 Pt 2): 1016-1023
    CrossrefPubMedGoogle Scholar
  • 10 Srinivas SK, Stamilio DM, Stevens EJ, Odibo AO, Peipert JF, Macones GA. Predicting failure of a vaginal birth attempt after cesarean delivery. Obstet Gynecol 2007; 109 (04) 800-805
    CrossrefPubMedGoogle Scholar
  • 11 Grobman WA, Gilbert S, Landon MB. et al. Outcomes of induction of labor after one prior cesarean. Obstet Gynecol 2007; 109 (2 Pt 1): 262-269
    CrossrefPubMedGoogle Scholar
  • 12 Lappen JR, Hackney DN, Bailit JL. Outcomes of term induction in trial of labor after cesarean delivery: analysis of a modern obstetric cohort. Obstet Gynecol 2015; 126 (01) 115-123
    CrossrefPubMedGoogle Scholar
  • 13 Al-Zirqi I, Daltveit AK, Forsén L, Stray-Pedersen B, Vangen S. Risk factors for complete uterine rupture. Am J Obstet Gynecol 2017; 216 (02) 165.e1-165.e8
    CrossrefPubMedGoogle Scholar
  • 14 Gregory KD, Korst LM, Fridman M. et al. Vaginal birth after cesarean: clinical risk factors associated with adverse outcome. Am J Obstet Gynecol 2008; 198 (04) 452.e1-452.e10 , discussion 452.e10–452.e12
    CrossrefPubMedGoogle Scholar
  • 15 Maternal Fetal Medicine Units Vaginal Birth After Cesarean Calculator. . Accessed August 25, 2021 at: https://mfmunetwork.bsc.gwu.edu/web/mfmunetwork/vaginal-birth-after-cesarean-calculator
    PubMed
  • 16 Grobman WA, Lai Y, Landon MB. et al; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Development of a nomogram for prediction of vaginal birth after cesarean delivery. Obstet Gynecol 2007; 109 (04) 806-812
    CrossrefPubMedGoogle Scholar
  • 17 Grobman WA, Lai Y, Landon MB. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Can a prediction model for vaginal birth after cesarean also predict the probability of morbidity related to a trial of labor?. Am J Obstet Gynecol 2009; 200 (01) 56.e1-56.e6
    CrossrefPubMedGoogle Scholar
  • 18 Vyas DA, Eisenstein LG, Jones DS. Hidden in plain sight - reconsidering the use of race correction in clinical algorithms. N Engl J Med 2020; 383 (09) 874-882
    CrossrefPubMedGoogle Scholar
  • 19 Grobman WA, Sandoval G, Rice MM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Prediction of vaginal birth after cesarean delivery in term gestations: a calculator without race and ethnicity. Am J Obstet Gynecol 2021; 225 (06) 664.e1-664.e7
    CrossrefPubMedGoogle Scholar
  • 20 Pierce H, Williams FB, McBride C, McLean K. "Maternal and neonatal morbidity associated with TOLAC versus elective repeat cesarean as a function of VBAC success prediction" in SRI 2020: Scientific Abstracts. Reprod Sci 2020; 27 (Suppl. 01) 122 https://doi.org/10.1007/s43032-020-00176-9.
    CrossrefPubMedGoogle Scholar
  • 21 Goodman D, Ogrinc G, Davies L. et al. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. BMJ Qual Saf 2016; 25 (12) e7
    CrossrefPubMedGoogle Scholar
  • 22 Anhøj J. Diagnostic value of run chart analysis: using likelihood ratios to compare run chart rules on simulated data series. PLoS One 2015; 10 (03) e0121349
    CrossrefPubMedGoogle Scholar
  • 23 R Core Team. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for Statistical Computing; 2013
    Google Scholar
  • 24 Anhøj J. qicharts2: quality improvement charts. R package version 0.7.1. 2020 . Accessed at: https://cloud.r-project.org/web/packages/qicharts2/index.html
    PubMedGoogle Scholar
  • 25 National Institutes of Health Consensus Development conference statement: vaginal birth after cesarean: new insights March 8-10, 2010. Obstet Gynecol 2010; 115 (06) 1279-1295
    CrossrefPubMedGoogle Scholar
  • 26 Silver RM, Landon MB, Rouse DJ. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107 (06) 1226-1232
    Google Scholar
  • 27 Macones GA, Cahill AG, Stamilio DM, Odibo A, Peipert J, Stevens EJ. Can uterine rupture in patients attempting vaginal birth after cesarean delivery be predicted?. Am J Obstet Gynecol 2006; 195 (04) 1148-1152
    CrossrefPubMedGoogle Scholar
  • 28 Grobman WA, Lai Y, Landon MB. et al; National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Prediction of uterine rupture associated with attempted vaginal birth after cesarean delivery. Am J Obstet Gynecol 2008; 199 (01) 30.e1-30.e5
    CrossrefPubMedGoogle Scholar
  • 29 Grove WM, Zald DH, Lebow BS, Snitz BE, Nelson C. Clinical versus mechanical prediction: a meta-analysis. Psychol Assess 2000; 12 (01) 19-30
    CrossrefPubMedGoogle Scholar
  • 30 Tolcher MC, Holbert MR, Weaver AL. et al. Predicting cesarean delivery after induction of labor among nulliparous women at term. Obstet Gynecol 2015; 126 (05) 1059-1068
    CrossrefPubMedGoogle Scholar
  • 31 Levine LD, Downes KL, Parry S, Elovitz MA, Sammel MD, Srinivas SK. A validated calculator to estimate risk of cesarean after an induction of labor with an unfavorable cervix. Am J Obstet Gynecol 2018; 218 (02) 254.e1-254.e7
    CrossrefPubMedGoogle Scholar
  • 32 Rossi RM, Requarth E, Warshak CR, Dufendach KR, Hall ES, DeFranco EA. Risk calculator to predict cesarean delivery among women undergoing induction of labor. Obstet Gynecol 2020; 135 (03) 559-568
    CrossrefPubMedGoogle Scholar
  • 33 Maykin MM, Mularz AJ, Lee LK, Valderramos SG. Validation of a prediction model for vaginal birth after cesarean delivery reveals unexpected success in a diverse american population. AJP Rep 2017; 7 (01) e31-e38
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Perez WM, Vricella LK, Gross GA, Tomlinson TM. Validity of the MFMU antenatal VBAC ‘calculator’ in the contemporary labor management era. Am J Obstet Gynecol 2019; 220 (01) S530-S531
    CrossrefPubMedGoogle Scholar