Consensus Statements and Real-World Implications

2014 ACOG / SNFM statement

In March, ACOG and SMFM released a consensus statement on prevention of primary cesareans. It made several significant recommendations, such as:

  • A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery.
  • Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor….
  • Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications. Inductions at 41 0/7 weeks.. should be performed to reduce the risk of cesarean delivery… perinatal morbidity and mortality.
  • Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g… [Note: that’s 11 pounds]

All potential game changers, right? And there’s more! If you haven’t read the statement yet, do. All childbirth educators would benefit from the info on typical length of pregnancy, length of labor, etc.

But, I find myself wondering. Will it be a game changer?

How much effect does a consensus statement (even a major one like this) have on actual practice and how long does it take for that effect to appear?

2010 VBAC Consensus Statement

So, let’s look back at another major consensus statement: Vaginal Birth after Cesarean, an NIH consensus statement from March 2010.

First, the context for the NIH consensus panel: This was at a time when VBAC rates had been dropping steadily since 1997. One factor in these dropping rates was availability of VBAC as an option. In 1999, ACOG released a practice guideline that trial of labor should only occur in hospitals where physicians and anesthesiologists are “immediately available” 24 hours a day to perform emergency cesareans. A joint statement from ACOG and ASA in 2008 re-affirmed this.  Surveys found that 30% of hospitals (especially smaller hospitals and rural facilities) stopped offering trial of labor because they could not provide immediate surgical and anesthesia services.

The NIH recommendations in 2010 included:

  • Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.
  • When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman’s preference should be honored.
  • We are concerned about the barriers that women face in gaining access to … trial of labor. Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel… we recommend [ACOG and ASA] reassess…

What effect did this NIH statement have on ACOG?

ACOG did update their clinical guidelines on VBAC in August of that year. There was some positive progress toward VBAC access there, such as the statement “Most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about vaginal birth after cesarean delivery (VBAC) and offered a trial of labor after previous cesarean delivery (TOLAC).” However, despite the NIH recommendation to reassess this requirement, they retained the wording “TOLAC [should] be undertaken in facilities with staff immediately available to provide emergency care”

What effect did the NIH statement have on VBAC rates?

In 2009, VBAC rate was 8.4%. The NIH statement was released in March of 2010. The 2010 rate was 9.2%, 2011 was 9.7%, and 2012 was 10.2%. [Data is not yet available for 2013.]

So, we have seen some improvement since the consensus statement, which is good news for VBAC advocates.

However, we are nowhere near the rates seen in the mid-1990’s before ACOG recommended “immediate access” requirement for hospitals allowing VBAC.

VBAC rate

Obviously, there are many factors at play in the VBAC rate, beyond the NIH recommendations and the ACOG Guidelines, such as financial reimbursements for procedures, liability concerns and more. Plus, practitioners may be slow to change their practice.

I suspect that some of the new guidelines from the 2014 ACOG / SMFM statement will become standard practice quickly, others are already being viewed as controversial, and are less likely to become standard practice.

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