Family physicians' VBAC guideline raises concerns: availability of surgical teams is at issue.(News)

New clinical guidelines issued by the American Academy of Family Physicians have raised concerns at the American College of Obstetricians and Gynecologists.

Under those guidelines, a trial of labor after cesarean section should be offered to all appropriate candidates, and not restricted to those in facilities with surgical teams that are immediately available and present throughout labor.

The recommendation differs from that of ACOG, which specifies that vaginal birth after cesarean (VBAC) should be attempted only in institutions equipped to respond to emergencies with immediately available physicians.

The AAFP based its new guidelines on the 2003 trial of labor report issued by the Agency for Healthcare Research and Quality and on numerous studies published since then. None of these data sources contained clinical evidence supporting a restriction of trial of labor to facilities with immediately available surgical teams, said AAFP President Mary Frank, M.D.

"The question is, have there been any studies showing that having the team onsite vs. in close proximity increases the risk of death or other problems or complications," she said in an interview. "There are just no studies that show an increase in loss of life or bad outcome because the team isn't immediately on site."

The new AAFP guidelines provoked heated comment from Gary Hankins, M.D., chairman of ACOG's Committee on Obstetric Practice. "It's very troubling when people who may not even be qualified to perform a cesarean section start issuing guidelines about the safety of this kind of thing," Dr. Hankins told this newspaper. "Their argument is that the available data don't prove it's unsafe--they're not arguing that it is safe. To me, the motive should be patient safety. Guidelines should be outcome-driven--and driven by good outcomes."

Although the AAFP guidelines don't restrict a trial of labor to certain facilities, they do specify that an individually constructed emergency management plan should be in place for each woman who attempts a trial of labor after cesarean (TOLAC). Such a plan would include being able to get a surgical team on site quickly. Dr. Frank said, "We're not saying attempt VBAC without surgical support. We understand the necessity for the team to be available close by, but that could be on another floor or across the street. We want our members to have a plan in place about how to access surgical support quickly."