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Comparing Rates of Trial of Labour Attempts, VBAC Success, and Fetal and Maternal Complications Among Family Physicians and Obstetricians
Balbina Russillo, MD, CCFP, FCFP,1,2,3 Maida J. Sewitch, PhD,1,4 Linda Cardinal, HRA,5 Normand Brassard, MD, FRCPC, MBA6,7
1 2 3 4 5 6 7
Department of Family Medicine, McGill University, Montreal QC Department of Obstetrics and Gynecology, St. Mary’s Hospital Center, Montreal QC Obstetrics Coordinator of the Family Medicine Unit, St. Mary’s Hospital Center, Montreal QC Department of Clinical Epidemiology and Community Studies, St. Mary’s Hospital Center, Montreal QC Quality Assessment Analyst, St. Mary’s Hospital Center, Montreal QC Department of Obstetrics and Gynecology Laval University, Quebec QC Obstetrician-gynecologist in Chief, Centre Hospitalier, Universitaire de Québec, Québec (Québec)
Objectives: To determine differences between family physicians and obstetricians in rates of trial of labour (TOL) attempt, vaginal birth after Caesarean section (VBAC) success, and maternal-fetal complications. Methods: We undertook a database evaluation study in an urban Quebec secondary care hospital centre that serves a multiethnic population. Study subjects were pregnant women with at least one previous Caesarean section (CS), who delivered singletons at St. Mary’s Hospital Center between January 1995 and December 2003. Outcomes were rates of TOL attempt, of VBAC success and failure, and of uterine rupture or dehiscence. Results: Of 32 500 singleton deliveries, 3694 (11.4%) women met study criteria. Of these, 3493 (94.6%) were patients of obstetricians, and 201 (5.4%) were patients of family physicians. The TOL attempt rate was 50.6% (1768) and 81.1% (163) for obstetricians and family physicians, respectively ( P < 0.001). For women having TOL, the VBAC success rate was 64.3% for obstetricians and 76.1% for family physicians (P = 0.002). Rates of uterine rupture or dehiscence in the combined failed and successful VBAC groups were 2.9% for obstetricians and 4.3% for family physicians (P = 0.33) whereas in the failed VBAC group the rates were 7.9% versus 17.9% for the family physicians (P = 0.04). Within delivery outcomes for successful and failed VBAC there were no differences in maternal characteristics and newborn outcomes by physician group.
Conclusion: More patients of family physicians than of obstetricians attempted TOL and had successful VBAC. Newborn outcomes were similar in the two groups, except that in the failed VBAC group, the family doctors had slightly higher uterine rupture or dehiscence rates; given the low power of this study, further studies are needed to confirm and explain this result. Also, given the similarity in patient profiles, the differences in delivery outcomes may be attributable to differences in physician practice styles.
Objectifs : Identifier les différences entre les médecins de famille et les obstétriciens en matière de taux d’essai de travail (EDT), de taux de réussite de l’accouchement vaginal après une césarienne (AVAC) et de taux de complications materno-fœtales. Méthodes : Nous avons mené une étude d’évaluation de base de données au sein d’un centre hospitalier de soins secondaires urbain québécois qui dessert une population multiethnique. Cette étude portait sur les femmes enceintes qui, ayant déjà connu au moins une césarienne, avaient accouché d’un enfant unique au St. Mary’s Hospital Center entre janvier 1995 et décembre 2003. Parmi les critères d’évaluation, on trouvait le taux d’EDT, les taux de réussite et d’échec de l’AVAC et le taux de rupture ou de déhiscence utérine. Résultats : Dans le cadre de notre étude, 3 694 (11,4 %) des 32 500 femmes ayant connu un accouchement simple ont satisfait aux critères de sélection. Parmi celles-ci, 3 493 (94,6 %) étaient des patientes d’obstétriciens et 201 (5,4 %) étaient des patientes de médecins de famille. Les taux d’EDT étaient de 50,6 % (1 768) dans le cas des obstétriciens et de 81,1 % (163) dans celui des médecins de famille (P < 0,001). Chez les femmes tentant un EDT, le taux de réussite de l’AVAC était de 64,3 % pour les obstétriciens et de 76,1 % pour les médecins de famille (P = 0,002). Les taux de rupture ou de déhiscence utérine totaux (combinaison des résultats des groupes « échec de l’AVAC » et « réussite de l’AVAC ») étaient de 2,9 % pour les obstétriciens et
Key Words: Caesarean section, trial of labour, vaginal birth after previous Caesarean section, uterine rupture, uterine dehiscence Competing Interests: None declared. Received on July 18, 2007 Accepted on September 21, 2007
FEBRUARY JOGC FÉVRIER 2008 l
ABBREVIATIONS CS TOL VBAC Caesarean section trial of labour vaginal birth after Caesarean section 124 l FEBRUARY JOGC FÉVRIER 2008 . how they could be explained and how management of these patients should be changed to decrease morbidity and mortality. The obstetricians take 24-hour in-house call and are available for emergency calls. Conclusion : Un plus grand nombre de patientes de médecins de famille. urban hospital in Montreal serving a large multiethnic population. The study included 13 family medicine physicians with obstetrical privileges (excluding performance of CS) and 30 obstetricians. aucune différence n’a été constatée entre les obstétriciens et les médecins de famille en matière de caractéristiques maternelles et d’issues néonatales. In general. and contains information on all deliveries performed at the hospital from 1993 to the present.6 Although the most frequent indications for CS are previous CS.5 However.2% in 2000–2001. Asia. after 1997. labour duration. for example with vacuum-assisted deliveries. Evidence suggests that family physicians and obstetricians take different approaches to the management of labour and delivery of women with previous CS. METHODS T he management of women with previous CS has long been subject to debate. reason for repeat CS.33). rupture of membranes. and in Canada from 6% in 1970 to 21. date of admission to caseroom. hypertension. d’autres études s’avèrent requises pour confirmer et expliquer ces résultats. complications. the VBAC rate steadily decreased to 10. The family physicians also have an on-call system but are not in-house 24 hours a day.12 When family physicians do intervene. The labour and delivery database is constructed from information recorded on standardized delivery forms that are part of the patients’ charts.8. CS indication (primary or failed VBAC). De plus. number of previous CS.3 In 1981. live or stillbirth. and the CS rate rose to approximately 27%.1 The overall rate of CS in the US has risen from 5% in 1970 to a high of 26% in 2002. and non-reassuring fetal status.2. with approximately 3500 deliveries per year. malpresentation. physicians in Europe. fever in labour. les différences en matière d’issues d’accouchement pourraient être attribuables à des différences en ce qui concerne les styles de pratique des médecins en question.9 % pour les médecins de famille (P = 0. Mary’s Hospital Center between January 1995 and December 2003. augmentation. their complication rates are similar to those of obstetricians. The study included all pregnant women who had at least one previous CS and who had a singleton pregnancy (birth weight at least 500 g) at St. and Africa are more inclined than those in the US and Canada to attempt a trial of vaginal delivery. Les issues néonatales étaient semblables dans les deux groupes.4 By the end of the 1980s. maternal hemorrhage.10.3 % pour les médecins de famille (P = 0. alors que dans le groupe « échec de l’AVAC ». The increased rate of uterine rupture and the subsequent concern for maternal and perinatal morbidity have challenged the safety of vaginal births after previous CS. it is not clear whether the management of VBAC deliveries differs according to physician speciality.11 For example.6% in 2003. dans le groupe « échec de l’AVAC ». fetal distress. trials of labour. partly because of rising medical-legal claims from adverse outcomes. Compte tenu de la faible envergure de cette étude. cependant. admitted with spontaneous or induced labour. presentation. par comparaison avec les patientes d’obstétriciens.04).OBSTETRICS de 4. the rate of VBAC had risen. reaching a peak of 28. the practice of repeat CS nonetheless exerts a major influence on the overall increase in CS rate7. indication for induction. Access to emergency CS and support for patients in labour was the same for both physician groups. Mary’s Hospital Center. obstetric history. J Obstet Gynaecol Can 2008. les taux étaient de 7. diabetes in pregnancy. with a CS rate of approximately 20%. number and rank of fetus. We extracted the following maternal and neonatal data from the database: gestational age by ultrasound. les médecins de famille ont connu des taux légèrement supérieurs de rupture ou de déhiscence utérine. compte tenu de la similarité des profils de patiente.13 However. and fetal and maternal complications between family practitioners and obstetricians and if there were differences. the US National Institutes of Health Consensus Development Task Force recommended that “properly selected” women should be encouraged to labour and deliver vaginally after a prior CS. a secondary care. ont tenté un EDT et connu un AVAC réussi. En ce qui concerne les issues d’accouchement au sein des groupes « échec de l’AVAC » et « réussite de l’AVAC ». concerned with the rising rate of CS. patient date of birth.9 An estimated 60% to The data source for this cross-sectional study was the labour and delivery database of the St. antibiotics in labour.9 % pour les obstétriciens et de 17. comparison of the intrapartum management by family physicians and obstetricians shows that family physicians intervene less often during labour without adversely affecting maternal or fetal outcome. The purpose of this study was to determine whether there were differences in rates of VBAC success. birth weight.3% in 1996. repeat CS accounted for 39% of all CS in 2001. dystocia.30(2):123–128 INTRODUCTION 82% of trials of labour after previous CS result in successful vaginal birth.
2% vs. 4.4%) were delivered by family physicians (Table 1). and Fetal and Maternal Complications Among Family Physicians and Obstetricians Table 1.8%.2 was higher for the family physician group than for the obstetrician group (17. The uterine rupture or dehiscence rate in the failed and successful VBAC group was 2.0) (4. Of the obstetrician group.6) (64. Maternal characteristics and intrapartum characteristics in the failed VBAC group were comparable between physician groups.001 0.001). complications following a failed VBAC were different: the uterine rupture or dehiscence rate was 7.7% (632) for obstetricians versus 23. Of these. 2. 11 (73%) were intrauterine fetal deaths occurring prior to admission. FEBRUARY JOGC FÉVRIER 2008 l 125 A total of 3694 pregnancies met study criteria.9% for the family physicians (P = 0. and four (27%) occurred after admission to hospital (2 fetal deaths occurred during labour).3% (7) for family physicians (P = 0.1% (124) in the family physician group (P = 0. RESULTS (13.. and cord pH in babies whose mothers had a successful VBAC were comparable between physician groups. 4. For the successful VBAC group. no TOL Total rupture or dehiscence Rupture or dehiscence in failed and successful VBAC groups n = 3493 1768 1136 1725 92 51 (94.9% (39) for family physicians (P = 0. There were no significant differences in augmentation of labour and complications (e.6) (2.9%).9) (4.002 < 0.4) (2.33 suspected neonatal anomalies. 3493 (94.02). (4) The VBAC uterine rupture or dehiscence rate was equal to the number of uterine ruptures and dehiscences divided by the number of women with prior CS.Comparing Rates of Trial of Labour Attempts.9% vs. Maternal and neonatal complications were similar in the two physician groups. cord pH value.4%) (81. as appropriate. 6.3% (1136) in the obstetrician group compared with 76.7%. Mean birth weight.4% vs. chi-square tests. 90%) than the obstetricians. diabetes . Apgar scores. P = 0. 7. Induction of labour rates were similar for the family physician and the obstetrician groups (Table 3).002). Statistical Analysis Descriptive statistics were used to characterize study subjects. (2) The VBAC success rate was equal to the number of VBACs divided by the number of women with TOL.05) (Table 5).3) P < 0. Subjects were compared using Student t tests. P = 0. P = 0. (3) The VBAC failure rate was equal to the number of CS divided by the number of women undergoing TOL.04). family physicians had a greater proportion of patients with a gestational age < 37 weeks (16. Table 2 shows the maternal characteristics according to VBAC outcome. However. 40. Of the 15 stillbirths recorded.9) Family physicians n = 201 163 124 38 8 7 (5.002).1% (163) of the family physician group (P < 0.6%) were delivered by obstetricians. The four study outcomes were defined as follows: (1) The TOL rate was equal to the number of women attempting vaginal delivery among women with prior CS divided by all women with prior CS. Rates of fever or chorioamnionitis as well as newborn characteristics were comparable (Tables 4 and 5). fever or chorioamnionitis) in the two groups.3) (49. Family physicians had a higher percentage of medical indications as the primary reason for repeat CS than the obstetrician group (57. and Fisher exact tests.1) (76.33). Conversely.9% vs.7% vs.9% (51) for obstetricians versus 4. For patients who underwent a repeat CS without TOL.2%. The VBAC success rate was 64.25 0.9% for the obstetricians and 17.6%) (50.g. However.001 0. 50. and 201 (5. P = 0.3% vs. respiratory depression. the VBAC failure rate was 35.002). and hypertension (7.1) (18. Summary of main outcomes Deliveries after previous CS 1995–2003 (N = 3694) Obstetricians Rates TOL VBAC success Repeat CS. Apgar score. and time of delivery.2%). family physicians had a higher percentage of patients with diabetes than obstetricians (11. the proportion of cord pH < 7.6% (1768) had a trial of labour compared with 81.07) and a lower proportion of patients between 37 and 41 weeks’ gestation (75% vs. VBAC Success.4%.
6% 5.6 Given the comparable patient profiles.9% 11. Although comparable percentages of patients in each physician group were eligible for a TOL.4 21.3 2.4 0.7 43. Current studies show that approximately 60% to 82% of TOL after previous CS result in successful vaginal delivery.0% 3. Intrapartum characteristics Successful VBAC Obstetricians Characteristics Induction Oxytocin Prostaglandin Amniotomy TOTAL Augmentation of labour 1st stage 2nd stage TOTAL 29.7% 83.7% 0.0% 4.002 Obstetricians 32.4 4. quoting success and failure rates.99 0.0 1.4 20.95 0.6% 0. of previous CS 1 2 3 or more 96.8% 28.5% 11.4% 0.5% 22.2 0.0% 12.3% 65.0% 0.0 2. Our database did 126 l FEBRUARY JOGC FÉVRIER 2008 not provide detailed descriptions of counselling by physicians.OBSTETRICS Table 2.1 P 0.41 0.1% 0.2 1.8 1.2 30.2% 5.7% for family physicians.3% 4.4 Family physicians 30.3% 94.45% 3. Family physicians had a higher VBAC success rate than obstetricians.3% 72.9% for obstetricians and 23. gestational age.7% 2. a well-defined protocol for TOL.0% 4. VBAC refusal rates were 35.8% 82..7 37.14 Table 3.60 28. and maternal comorbidities (diabetes and hypertension).9% 5.8 29. To avoid physician bias.62 Obstetricians 31.23 Obstetricians % Failed VBAC Family physicians % P 0.14 can be used to select all eligible patients for specific counselling.9 0. this was not explained by patient profiles.5 2.8% 0.99 8. family physicians had a higher TOL attempt rate than obstetricians.2 0.6% 0. The higher rate of patient refusal in the obstetrician group may have resulted from the way in which physicians counselled patients on TOL. This would be feasible in a future study.5 0.1% 2.08 % Family physicians % P 0. The one exception was that family physicians had a higher percentage of patients with gestational diabetes in the successful VBAC group.6 2.76 0.002 0.3% 5.2% 0.6 0.21 94. which were similar in terms of the maternal age.52 32.2 P 0.6 0. number of previous CS.99 DISCUSSION In this study. as used in a study by Gonen et al.47 18.0 35.8 40.9% 0. it is possible that the higher VBAC success rate among family physicians was due to .76 0.3% 5.8 34.4% 99.1 The observed VBAC success rate among family physicians is consistent with the pooled vaginal delivery rate obtained in prospective studies (76%).2 Failed VBAC Family physicians 31.4 33.8 6.4 22. Maternal characteristics Successful VBAC Characteristics Maternal age (mean) Maternal comorbidity Diabetes Hypertension Gestational age < 37 weeks 37–41 weeks > 41 weeks No.84 5.5 35.
The labour and delivery database was validated FEBRUARY JOGC FÉVRIER 2008 l 127 .99 3.9% vs. Fetal characteristics Successful VBAC Obstetricians Characteristics Birth weight < 2500 g 2500–4000 g > 4000 g Apgar score £ 3 at 1 min £ 6 at 5 min Cord pH < 7.16 Although family physicians may be less interventionist than obstetricians.60 0.9% P = 0. Because family physicians do not perform CS.0 2.88 Failed VBAC Family physicians % 17.6 2. the uterine rupture or dehiscence rate was also lower for the obstetrician group and statistically significant (7.7 Table 5.99 0.99 3. macrosomia. VBAC Success. The uterine rupture or dehiscence rate for patients in the obstetrician group was slightly lower than the rate for those in the family physician group. 17.g.) versus performing a repeat CS because of patient wishes.9 12.15.49 Obstetricians Complication Uterine rupture or dehiscence Fever/ chorioamnionitis % 0.81 2.2 0. a higher percentage of those in the family physician group than in the obstetrician group had gestational diabetes. physician style of practice may have influenced the patient’s decision.5 9. no TOL Family physicians % 2. Again.4 87.0 0.4 1.. Unclear definitions for rupture and dehiscence in our database made it impossible for us to study the two rates separately.2 81.2 7.6 P 0. Of patients who underwent a repeat CS without TOL.6 87.05 8. diabetes. intraspecialty differences in the way providers treat similar conditions are well documented.62 0. Our data should be interpreted in light of these study limitations. Family physicians had a higher percentage of patients who underwent a repeat CS for medical reasons (e. history of cephalic-pelvic disproportion. and the morbidity of uterine rupture could not be isolated from that of uterine dehiscence.Comparing Rates of Trial of Labour Attempts.1 4. they also do not have the option to perform CS. placenta previa.04 0.8 17.50 3. this in turn may explain the increased morbidity in terms of uterine rupture or dehiscence in the family physician group. given the similar patient profiles. In the successful VBAC group. In the failed VBAC group. this could have affected their management and may have prolonged the time before the decision to perform a CS. and Fetal and Maternal Complications Among Family Physicians and Obstetricians Table 4.3 Obstetricians % 7.10 Repeat CS.05).0 0. the percentage of babies with a cord pH < 7.1 10.6 3.8 P 0. Nevertheless.1 2. The clinical significance of this observation is difficult to interpret because our data did not allow us to further subdivide the cords with pH < 7.5 % Family physicians % P 0.3 Obstetricians % Failed VBAC Family physicians % P 0.2 10.6 16. Complications rates Successful VBAC Family physicians % 0. this finding is of concern and requires further study.2 was statistically significantly higher in the family physician group than in the obstetrician group (P = 0.99 0.0 Obstetricians % 2. history of myomectomy.4 2.2 2.04).3 0.4 0.6 2.0 2. etc.62 different physician management approaches or styles during labour.3 87.0 4.0.0 P 0.4 0. which would have provided a better predictor of fetal compromise.9 6.
075 patients who attempted vaginal birth after Caesarean delivery: a review of the literature. Rates of maternal and neonatal complications between the physician groups were comparable for all categories except the failed VBAC group. Feb 2005. single birth. Johnson T. A. it may be possible to increase VBAC delivery rates without increasing maternal and fetal morbidity and mortality. details of counselling discussions were not available on our database. Birtwhistle R. Tamir A. Biswas. Eisenberg JM. Mary’s Hospital Center. 7. Guidelines for vaginal birth after previous Caesarean birth.OBSTETRICS against the hospital database and some medical charts for variables including delivery type. Yarrow C. Voaklander K. Raine TR.1:20–7.32:533–40. Martel M. Obstet Gynecol 2006.18 and thickness of the lower uterine segment.87(3):344–51.2003:33.27:164–74. in which family physicians had a higher uterine rupture or dehiscence rate than obstetricians. J Obstet Gynaecol Can 2005. 18. Bujold E.37(5):457–62. Schneeweiss R. JAMA 2002. Magann E. Sewitch. uterine rupture. 12. March 2003. Washington.A. Ohel G.15:123–201.96(2):308–313. 11. 17. Maida J. these findings may be the result of different practice styles between the physician specialties. Apgar B.C). PhD is a Research Scientist of the Canadian Cancer Society through an award from the National Cancer Institute of Canada. of the advantages and disadvantages of each mode of delivery and (2) that criteria for intrapartum management must be applied to improve the VBAC success rate without increasing morbidity.107:240–5. Rosenblatt R. Is VBAC a viable option for Canadian Women? J Obstet Gynaecol Can 2005. et al. J Fam Pract 1993. Dodie S. SOGC Clinical Practice Guidelines. Results of a well-defined protocol for a Trial of Labor After Prior Cesarean Delivery. Martin J. Chauhan S. For all treating physicians. Vaginal birth after Cesarean deliveries. 9. Management of previous Cesarean section. Can Fam Physician 1986. Int J Technol Assess Health Care 1987. DC: Department of Health & Human Services.189(2):408–16. Gauthier R. 2. such as a one-layer interlocking closure. a validation of the entire database was not attempted. Although these more recently identified risk factors will help physicians to better select appropriate candidates for TOL in future. Pub N0. Interspeciality differences in the obstetric care of low risk women. No. 4. Bujold C. Fam Pract Res J 1981. Cheung VY. previous CS. Given the similarity in patient profiles. The Canadian family practice accoucheur. Maternal & perinatal complication with uterine rupture in 142. 155. Health Canada. National Health Promotion & Disease Prevention Objectives. Rockville MD: AMRQ Publication No. United States Department of Health & Human Service. Obstet Gynecol 2000. In our hospital labour and delivery database study. we had no knowledge of this information and no such data were recorded in the hospital database. the reasons given by patients and physicians for repeat CS and for refusal of TOL may not reflect the true reasons. Am J Obstet Gynecol 2003. Sonographic measurement of the lower uterine segment thickness in women with previous Caesarean section. Physician utilization: the state of research about physicians’ practice patterns. Curr Opin Obstet Gynecol 2003. Strategies for reducing medical costs by changing physicians’ behavior and impact on quality of care. Henrichs C. Can Fam Physician 2004. Schroeder SA. in a standardized way. 03-E018. 91–50212. 14. stillbirth. Comparison of family physicians’& obstetricians’ intrapartum management of low risk pregnancies.1990. Lalonde AB. Mackinnon C. Hamilton EF. 8.287(20):22–9. 10. 15. Audit of obstetrical care: comparison between family practitioners and obstetricians. 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