VBAC mortality unchanged after guideline issued.(Obstetrics)

NEW ORLEANS -- Neonatal and maternal mortality in California did not significantly change after the American College of Obstetricians and Gynecologists recommended vaginal births after cesarean delivery be performed only in settings with "immediately available" emergency care, according to a study.

Very low-birth-weight infants were the only group to experience significantly higher mortality associated with vaginal births after cesarean (VBACs). When the American College of Obstetricians and Gynecologists (ACOG) was contacted for comment, a representative criticized the study design and its implications.

In 1996, ACOG encouraged VBACs, John Zweifler, M.D., said at the annual conference of the Society of Teachers of Family Medicine. In 1998, the college changed its recommendations on VBACs and stated they should be attempted only where emergency care is "readily available." The following year, ACOG further restricted the recommendations to settings where emergency care is "immediately available." The college retained the wording of these recommendations in its latest update, Practice Bulletin No. 54 (Obstet. Gynecol. 2004;104:203-12).

"But for those of us in rural settings, this could impair our ability to do VBACs," Dr. Zweifler said. "We were concerned that a change in ACOG guidelines would have deleterious effect on our [residency] program."

Dr. Zweifler and research fellow Susan Hughes compared neonatal and maternal deaths from 1996 to 2002. They reviewed maternal demographics, birth data, and outcomes, noting previous C-sections and whether hospitals were in rural or urban areas. California Birth Statistical Master Files consider mortality to be associated with birth if it occurs within 72 hours of delivery, said Dr. Zweifler, director of the University of California, San Francisco's Fresno Family Medicine Residency Program.

There were more than 3.5 million single births in California in the seven years, including 2.7 million vaginal births, 456,000 primary cesarean sections, and 386,000 deliveries to women with a history of C-section. Of the women with a history of cesarean delivery, 311,000 had a repeat cesarean, and 74,000 had an attempted VBAC. There were ...