Inconsistent Evidence: Analysis of Six National Guidelines for Vaginal Birth After Cesarean Section

Abstract: Background: Guidelines are increasingly used to direct clinical practice, with the expectation that they improve clinical outcomes and minimize health care expenditure. Several national guidelines for vaginal birth after cesarean section (VBAC) have been released or updated recently, and their range has created dilemmas for clinicians and women. The purpose of this study was to summarize the recommendations of existing guidelines and assess their quality using a standardized and validated instrument to determine which guidelines, if any, are best able to guide clinical practice. Methods: English language guidelines on VBAC were purposively selected from national and professional organizations in the United Kingdom, United States, Canada, New Zealand, and Australia. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was applied to each guideline, and each was analyzed to determine the range and level of evidence on which it was based and the recommendations made. Results: Six guidelines published or updated between 2004 and 2007 were examined. Only two of the six guidelines scored well overall using the AGREE instrument, and the evidence used demonstrated great variety. Most guidelines cited expert opinion and consensus as evidence for some recommendations. Reported success rates for VBAC ranged from 30 to 85 percent, and reported rates of uterine rupture ranged from 0 to 2.8 percent. Conclusions: VBAC guidelines are characterized by quasi‐experimental evidence and consensus‐based recommendations, which lead to wide variability in recommendations and undermine their usefulness in clinical practice. (BIRTH 37:1 March 2010)     

Medium-term Follow-up of the Intravaginal Slingplasty Operation Indicates Minimal Deterioration of Urinary Continence With Time

An assessment of the medium term efficacy of stress incontinence cure in a group of patients who had undergone the intravaginal slingplasty (IVS) operation is presented. Eighty-five unselected patients, aged 27 to 83 years at the time of surgery, 12 with pure stress symptoms, and 73 with mixed incontinence symptoms underwent the IVS procedure between 31 and 57 months previously (mean 3.9 years). The patients were assessed with the same self-administered semiquantitative questionnaire used in the initial assessment. The results were compared with the original cure rate which was 88% at 1.75 years with another 2.5% more than 70% improved (total 90.5%). The cure rate in the 75 patients assessed at 3.9 years was 81%, with another 8% reporting more than 70% improvement (total 89%). Included in the latter were 2 patients who, though originally designated as failures, gradually achieved almost 100% continence within 2 years of surgery. Deterioration of continence following the IVS operation appears more like the Burch colposuspension than needle suspensions. It is possible to explain deterioration of continence with time in terms of age-related connective tissue laxity of the vaginal hammock. Improvement in 2 women with time can be explained by tightening of the hammock via paraurethral scar contraction with time. Whether the IVS operation improves or deteriorates in the longer term may depend on which process predominates.     

Planned Place of Birth in New Zealand: Does it Affect Mode of Birth and Intervention Rates Among Low‐Risk Women?

Abstract: Background: Midwives providing care as lead maternity caregivers in New Zealand provide continuity of care to women who may give birth in a variety of settings, including home, primary units, and secondary and tertiary level hospitals. The purpose of this study was to compare mode of birth and intrapartum intervention rates for low‐risk women planning to give birth in these settings under the care of midwives. Methods: Data for a cohort of low‐risk women giving birth in 2006 and 2007 were extracted from the Midwifery Maternity Provider Organisation database. Mode of birth, intrapartum interventions, and neonatal outcomes were compared with results adjusted for age, parity, ethnicity, and smoking. Results: Women planning to give birth in secondary and tertiary hospitals had a higher risk of cesarean section, assisted modes of birth, and intrapartum interventions than similar women planning to give birth at home and in primary units. The risk of emergency cesarean section for women planning to give birth in a tertiary unit was 4.62 (95% CI: 3.66–5.84) times that of a woman planning to give birth in a primary unit. Newborns of women planning to give birth in secondary and tertiary hospitals also had a higher risk of admission to a neonatal intensive care unit (RR: 1.40, 95% CI: 1.05–1.87; RR: 1.78, 95% CI: 1.31–2.42) than women planning to give birth in a primary unit. Conclusions: Planned place of birth has a significant influence on mode of birth and rates of intrapartum intervention in childbirth. (BIRTH 38:2 June 2011)