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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
with a CS rate of approximately 20%. and in Canada from 6% in 1970 to 21.3 In 1981. augmentation. complications. and the CS rate rose to approximately 27%. dystocia.12 When family physicians do intervene. obstetric history. the practice of repeat CS nonetheless exerts a major influence on the overall increase in CS rate7. presentation. Asia. physicians in Europe. compte tenu de la similarité des profils de patiente. reason for repeat CS. ABBREVIATIONS CS TOL VBAC Caesarean section trial of labour vaginal birth after Caesarean section 124 l FEBRUARY JOGC FÉVRIER 2008 . 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. and Africa are more inclined than those in the US and Canada to attempt a trial of vaginal delivery.9 % pour les obstétriciens et de 17.2. The labour and delivery database is constructed from information recorded on standardized delivery forms that are part of the patients’ charts. a secondary care. and non-reassuring fetal status. cependant. Les issues néonatales étaient semblables dans les deux groupes.9 An estimated 60% to The data source for this cross-sectional study was the labour and delivery database of the St. birth weight. date of admission to caseroom. Compte tenu de la faible envergure de cette étude. De plus. alors que dans le groupe « échec de l’AVAC ». partly because of rising medical-legal claims from adverse outcomes.6 Although the most frequent indications for CS are previous CS. Access to emergency CS and support for patients in labour was the same for both physician groups. admitted with spontaneous or induced labour. The study included 13 family medicine physicians with obstetrical privileges (excluding performance of CS) and 30 obstetricians. antibiotics in labour. Mary’s Hospital Center. les médecins de famille ont connu des taux légèrement supérieurs de rupture ou de déhiscence utérine. patient date of birth. diabetes in pregnancy. urban hospital in Montreal serving a large multiethnic population. and contains information on all deliveries performed at the hospital from 1993 to the present. indication for induction. dans le groupe « échec de l’AVAC ».30(2):123–128 INTRODUCTION 82% of trials of labour after previous CS result in successful vaginal birth.1 The overall rate of CS in the US has risen from 5% in 1970 to a high of 26% in 2002. The obstetricians take 24-hour in-house call and are available for emergency calls. for example with vacuum-assisted deliveries.OBSTETRICS de 4. number of previous CS. fever in labour. trials of labour.3 % pour les médecins de famille (P = 0. Conclusion : Un plus grand nombre de patientes de médecins de famille. and fetal and maternal complications between family practitioners and obstetricians and if there were differences.3% in 1996. We extracted the following maternal and neonatal data from the database: gestational age by ultrasound. CS indication (primary or failed VBAC). Mary’s Hospital Center between January 1995 and December 2003. METHODS T he management of women with previous CS has long been subject to debate. concerned with the rising rate of CS. les taux étaient de 7. live or stillbirth.11 For example. their complication rates are similar to those of obstetricians. En ce qui concerne les issues d’accouchement au sein des groupes « échec de l’AVAC » et « réussite de l’AVAC ». 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. it is not clear whether the management of VBAC deliveries differs according to physician speciality. with approximately 3500 deliveries per year. ont tenté un EDT et connu un AVAC réussi.8.6% in 2003. The family physicians also have an on-call system but are not in-house 24 hours a day.9 % pour les médecins de famille (P = 0. Evidence suggests that family physicians and obstetricians take different approaches to the management of labour and delivery of women with previous CS. J Obstet Gynaecol Can 2008. how they could be explained and how management of these patients should be changed to decrease morbidity and mortality. fetal distress. 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. maternal hemorrhage.33). d’autres études s’avèrent requises pour confirmer et expliquer ces résultats. aucune différence n’a été constatée entre les obstétriciens et les médecins de famille en matière de caractéristiques maternelles et d’issues néonatales.4 By the end of the 1980s. after 1997. malpresentation. rupture of membranes. the rate of VBAC had risen. number and rank of fetus. repeat CS accounted for 39% of all CS in 2001. In general. hypertension. the VBAC rate steadily decreased to 10. 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.2% in 2000–2001.5 However. The purpose of this study was to determine whether there were differences in rates of VBAC success.10. par comparaison avec les patientes d’obstétriciens.04). labour duration.13 However. reaching a peak of 28. 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.
P = 0. 4. and Fetal and Maternal Complications Among Family Physicians and Obstetricians Table 1.9% (39) for family physicians (P = 0.002). Of these.002 < 0. the VBAC failure rate was 35.0) (4. and 201 (5.2%).6% (1768) had a trial of labour compared with 81. Of the obstetrician group.33). Mean birth weight. 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.3% (7) for family physicians (P = 0.g. Apgar score. Of the 15 stillbirths recorded. P = 0. Family physicians had a higher percentage of medical indications as the primary reason for repeat CS than the obstetrician group (57. Induction of labour rates were similar for the family physician and the obstetrician groups (Table 3). 40. the proportion of cord pH < 7.1) (76.001 0. complications following a failed VBAC were different: the uterine rupture or dehiscence rate was 7. family physicians had a greater proportion of patients with a gestational age < 37 weeks (16.9% vs. family physicians had a higher percentage of patients with diabetes than obstetricians (11. 90%) than the obstetricians. Maternal and neonatal complications were similar in the two physician groups. 11 (73%) were intrauterine fetal deaths occurring prior to admission.8%.6%) (50. However.6) (64.2% vs. 4. no TOL Total rupture or dehiscence Rupture or dehiscence in failed and successful VBAC groups n = 3493 1768 1136 1725 92 51 (94. Conversely.001 0. diabetes .05) (Table 5).3% (1136) in the obstetrician group compared with 76.Comparing Rates of Trial of Labour Attempts. Maternal characteristics and intrapartum characteristics in the failed VBAC group were comparable between physician groups.9) Family physicians n = 201 163 124 38 8 7 (5.4%) were delivered by family physicians (Table 1). as appropriate.002).2 was higher for the family physician group than for the obstetrician group (17. The VBAC success rate was 64.3% vs.4%. and cord pH in babies whose mothers had a successful VBAC were comparable between physician groups. Summary of main outcomes Deliveries after previous CS 1995–2003 (N = 3694) Obstetricians Rates TOL VBAC success Repeat CS. (3) The VBAC failure rate was equal to the number of CS divided by the number of women undergoing TOL. 50. FEBRUARY JOGC FÉVRIER 2008 l 125 A total of 3694 pregnancies met study criteria.04). (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. and four (27%) occurred after admission to hospital (2 fetal deaths occurred during labour).002). Table 2 shows the maternal characteristics according to VBAC outcome. chi-square tests.3) (49.001). fever or chorioamnionitis) in the two groups.7% vs. There were no significant differences in augmentation of labour and complications (e. VBAC Success.02).7% (632) for obstetricians versus 23.4%) (81.1% (124) in the family physician group (P = 0.7%. Apgar scores. 2. 3493 (94.9% for the family physicians (P = 0. P = 0.2%. (2) The VBAC success rate was equal to the number of VBACs divided by the number of women with TOL.1) (18.9% vs.4% vs. P = 0.9) (4. and hypertension (7. RESULTS (13.1% (163) of the family physician group (P < 0. For the successful VBAC group.25 0. and time of delivery.3) P < 0. and Fisher exact tests.07) and a lower proportion of patients between 37 and 41 weeks’ gestation (75% vs. However. Statistical Analysis Descriptive statistics were used to characterize study subjects.6%) were delivered by obstetricians. The uterine rupture or dehiscence rate in the failed and successful VBAC group was 2.4) (2.9%).9% (51) for obstetricians versus 4.33 suspected neonatal anomalies. cord pH value. 7. 6.6) (2. For patients who underwent a repeat CS without TOL.9% for the obstetricians and 17.. Subjects were compared using Student t tests. respiratory depression. Rates of fever or chorioamnionitis as well as newborn characteristics were comparable (Tables 4 and 5).
84 5.1 P 0.4 20. it is possible that the higher VBAC success rate among family physicians was due to . Maternal characteristics Successful VBAC Characteristics Maternal age (mean) Maternal comorbidity Diabetes Hypertension Gestational age < 37 weeks 37–41 weeks > 41 weeks No.7% 83.08 % Family physicians % P 0.9% 5. To avoid physician bias.3% 5.8 40.21 94.5% 22.8 29.4 0.0% 4.4 33.0% 4.95 0.2% 0. number of previous CS. as used in a study by Gonen et al.4 21. this was not explained by patient profiles.6% 0.47 18.6% 5.5% 11.4 Family physicians 30. Current studies show that approximately 60% to 82% of TOL after previous CS result in successful vaginal delivery.6 0.1 The observed VBAC success rate among family physicians is consistent with the pooled vaginal delivery rate obtained in prospective studies (76%). This would be feasible in a future study.23 Obstetricians % Failed VBAC Family physicians % P 0.3% 5.2 1.41 0.52 32. The one exception was that family physicians had a higher percentage of patients with gestational diabetes in the successful VBAC group.4 4.62 Obstetricians 31.8% 0.6 Given the comparable patient profiles.8% 82. VBAC refusal rates were 35. Our database did 126 l FEBRUARY JOGC FÉVRIER 2008 not provide detailed descriptions of counselling by physicians.7 43.3% 72.0% 0. quoting success and failure rates.5 35.OBSTETRICS Table 2.1% 2.002 0.0 35.8 6.9% 11. of previous CS 1 2 3 or more 96.2 0.76 0.7% 0.2 0.6% 0.2% 5.2 P 0.002 Obstetricians 32.9 0.99 DISCUSSION In this study.45% 3..3% 94.0% 3. Intrapartum characteristics Successful VBAC Obstetricians Characteristics Induction Oxytocin Prostaglandin Amniotomy TOTAL Augmentation of labour 1st stage 2nd stage TOTAL 29. gestational age.14 Table 3.4% 0.5 2.8 1. family physicians had a higher TOL attempt rate than obstetricians.9% 0. The higher rate of patient refusal in the obstetrician group may have resulted from the way in which physicians counselled patients on TOL.99 8. which were similar in terms of the maternal age.4 22.0% 12.7% 2.14 can be used to select all eligible patients for specific counselling. and maternal comorbidities (diabetes and hypertension).8% 28.2 Failed VBAC Family physicians 31.0 1.4% 99.8 34.3% 65. a well-defined protocol for TOL.6 2. Although comparable percentages of patients in each physician group were eligible for a TOL. Family physicians had a higher VBAC success rate than obstetricians.5 0.6 0.0 2.9% for obstetricians and 23.2 30.3% 4.7 37.99 0.3 2.60 28.1% 0.7% for family physicians.76 0.
Family physicians had a higher percentage of patients who underwent a repeat CS for medical reasons (e.2 was statistically significantly higher in the family physician group than in the obstetrician group (P = 0. the uterine rupture or dehiscence rate was also lower for the obstetrician group and statistically significant (7.99 3. a higher percentage of those in the family physician group than in the obstetrician group had gestational diabetes.5 % Family physicians % P 0. macrosomia. physician style of practice may have influenced the patient’s decision.3 0. and the morbidity of uterine rupture could not be isolated from that of uterine dehiscence.81 2.6 P 0.05 8.6 2.99 3. this finding is of concern and requires further study. Complications rates Successful VBAC Family physicians % 0.1 4.99 0. Of patients who underwent a repeat CS without TOL.0 2.6 3. etc. Again.49 Obstetricians Complication Uterine rupture or dehiscence Fever/ chorioamnionitis % 0. VBAC Success.0 0.1 10. they also do not have the option to perform CS.04).99 0. given the similar patient profiles.50 3.9 6.0.5 9.Comparing Rates of Trial of Labour Attempts.16 Although family physicians may be less interventionist than obstetricians. intraspecialty differences in the way providers treat similar conditions are well documented.6 2.05).1 2.62 0.3 Obstetricians % 7.9% P = 0.0 4.) versus performing a repeat CS because of patient wishes. In the successful VBAC group.2 81. Unclear definitions for rupture and dehiscence in our database made it impossible for us to study the two rates separately.2 7.g.9% vs. this could have affected their management and may have prolonged the time before the decision to perform a CS. diabetes.3 87. history of myomectomy. The clinical significance of this observation is difficult to interpret because our data did not allow us to further subdivide the cords with pH < 7.4 1. Nevertheless. In the failed VBAC group. The labour and delivery database was validated FEBRUARY JOGC FÉVRIER 2008 l 127 . and Fetal and Maternal Complications Among Family Physicians and Obstetricians Table 4.0 2..0 Obstetricians % 2. which would have provided a better predictor of fetal compromise. 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.8 17.8 P 0. Our data should be interpreted in light of these study limitations.6 16. this in turn may explain the increased morbidity in terms of uterine rupture or dehiscence in the family physician group.4 87. 17.7 Table 5.9 12.10 Repeat CS.2 0.60 0.62 different physician management approaches or styles during labour.2 2.15.88 Failed VBAC Family physicians % 17. the percentage of babies with a cord pH < 7.4 0.4 2. 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 < 7.04 0.4 0. history of cephalic-pelvic disproportion. no TOL Family physicians % 2.0 0.6 87.0 P 0.2 10.3 Obstetricians % Failed VBAC Family physicians % P 0. Because family physicians do not perform CS. placenta previa.
Lalonde AB. Martin J. 8. Sonographic measurement of the lower uterine segment thickness in women with previous Caesarean section. 13. and there was no standard counselling guide or questionnaire that all staff used. Tamir A.37(5):457–62. Washington.87(3):344–51. in a standardized way. Certain risk factors that are known today but not at the time of our study. 9. A. Eisenberg JM. 19. Yarrow C. However.OBSTETRICS against the hospital database and some medical charts for variables including delivery type.075 patients who attempted vaginal birth after Caesarean delivery: a review of the literature. Harer WB. Management of previous Cesarean section. Is VBAC a viable option for Canadian Women? J Obstet Gynaecol Can 2005.17 interdelivery interval (within 18–24 months). 3. Med Care 1985. Martel M. Am J Obstet Gynecol 2002. and birth weight. Curr Opin Obstet Gynecol 2003. Obstet Gynecol 2006. Bujold E. single birth. Biswas. J Obstet Gynaecol Can 2005. 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