RESEARCH27 UPDATES 28 29 30 Vaginal birth after Albany mdwifery Neonatal outcomes Review of midwives mapping cesarean delivery practice outcomes with water birth integration across the US ACOG practice bulletin: Vaginal birth after cesarean delivery Reviewed by KELSEY SCHERER, CPM American College of Obstetricians and Level A Recommendations (Based on good and consistent scientific evidence) Gynecologists’ committee on • Most people with one previous cesarean delivery with a low-transverse incision are candidates practice bulletins-obstetrics. for and should be counseled about and ofered TOLAC. Practice bulletin no. 184: • Misoprostol should not be used for cervical ripening or labor induction in those at term who Vaginal birth after cesarean have had a cesarean delivery or major uterine surgery. delivery. Obstet Gynecol. Level B Recommendations (Based on limited or inconsistent scientific evidence) 2017 Nov;130(5):e217–e233. • People at high risk of uterine rupture, including those with a history of classical uterine incision, TRIAL OF LABOR AFTER T-incision, prior uterine rupture, or extensive transfundal surgery, are not generally candidates cesarean delivery (TOLAC) for planned TOLAC. is a planned attempt to • It is reasonable to consider people with a history of two previous low-transverse cesarean delivery vaginally by a deliveries to be candidates for TOLAC and to counsel them based on their combination of other pregnant person who has factors afecting their likelihood of VBAC success. had a previous cesarean • External cephalic version for breech presentation is not contraindicated for those with a history delivery. Achieving a vaginal of low-transverse incision who are candidates for external cephalic version and TOLAC. birth after cesarean (VBAC) • People with a history of one 3-transverse incision, who are otherwise appropriate candidates is one outcome of TOLAC, for twin vaginal delivery, are candidates for TOLAC. with repeat cesarean being • Induction of labor remains an option for people undergoing TOLAC. another possible outcome • Continuous fetal heart rate monitoring during TOLAC is recommended. of TOLAC. The achievement of VBAC avoids major Level C Recommendations (Based primarily on consensus and expert opinion) abdominal surgery, results in • Because of the risks associated with TOLAC, and because uterine rupture and other lower rates of hemorrhage, complications may be unpredictable, TOLAC should be attempted in a facility capable of thromboembolism, and performing emergency delivery. When resources for emergency delivery are not available, infection and decreases risks in ACOG recommends that providers and patients discuss the available resources and availability of obstetric, pediatric, anesthesiology, and operating room stafs. future pregnancies of various sequelae including abnormal • Because of the unpredictability of complications requiring emergency medical care, home birth placentation. Achieving VBAC is contraindicated for a person undergoing TOLAC. results in fewer complications than elective repeat cesarean without a trial of labor, whereas Factors to be considered TOLAC and VBAC based evidence. Those include a failed TOLAC is associated include location and type of on evidence, consensus, that people with a history with more complication than prior uterine incision, history and opinion. Level A of classical uterine incision, elective repeat cesarean. The of other uterine surgery, recommendations are those T-incision, prior uterine most serious risk associated number of previous cesareans, based on good and consistent rupture, or history of with TOLAC is uterine estimated fetal weight, scientifc evidence. These transfundal surgery are rupture or dehiscence. maternal obesity, possibility include that a person with one recommended to deliver via In 60% to 80% of TOLAC of future pregnancies, patient previous cesarean delivery cesarean section, those with cases, VBAC is achieved. The interest in TOLAC, and patient with a low-transverse incision a history of two previous probability of achieving a VBAC understanding and acceptance should be offered TOLAC, cesarean deliveries with varies depending on individual of the beneft and risk of and that misoprostol is not low-transverse incisions are factors for each person. Each TOLAC. an acceptable medication for reasonable candidates for person’s candidacy for TOLAC In this article, the American induction in patients with a TOLAC, external cephalic should be determined by that College of Obstetricians history of any major uterine version for breech presentation person and their care provider and Gynecologists (ACOG) surgery including cesarean. is not contraindicated for considering individual factors evaluates scientifc evidence Level B recommendations those with a history of low- alongside the general risks and then makes graded are those based on limited transverse incision, induction and benefts of TOLAC. recommendations regarding or inconsistent scientifc continued on page 28 SPRING 2018 / 27 RESEARCH UPDATES continued from page 27 Midwifery continuity of care in an area of high socio-economic of labor is an appropriate disadvantage in London: A retrospective analysis of Albany Midwifery option for people undergoing Practice outcomes using routine data (1997–2009) TOLAC, and continuous fetal HEIDI FILLMORE, CPM heart rate monitoring should Reviewed by be utilized during TOLAC. Level C recommendations Caroline SE Homer, RM, are those based primarily on MMed(ClinEpi), PhD consensus and expert opinion. Professor, Nicky Leap, The Level C recommendation DMid Adjunct Professor that trial of labor after of Midwifery, Nadine previous cesarean delivery Edwards, PhD Independent take place in a facility capable Researcher, Jane Sandall, of performing emergency PhD, CBE Professor and cesarean remains. The ACOG, NIHR Senior Investigator. the Society for Maternal- Midwifery continuity of care Fetal Medicine, and various in an area of high socio- international guidelines economic disadvantage in are in agreement on this London: A retrospective COM recommendation. The ACOG analysis of Albany Midwifery . acknowledges that this may Practice outcomes using limit access to TOLAC, while routine data (1997–2009). also stating that restricting REAMSTIME Midwifery. 2017. May; 48: D access was not the intention 1-10. of this recommendation. | 02 Rather, the majority of data IN 2009, THE KING’S COLLEGE ERGEY S on safety of TOLAC is from Hospital in South East centers capable of performing London, England closed the ing its clients full access to in controversy and received emergency cesarean delivery, Albany Midwifery Practice, a medical and social services at much publicity. The fact that and therefore the safety service that had been serving no cost. The contract specifed Albany attended nearly half of of TOLAC can only be this diverse and socially that Albany would serve 216 the births in the clients home assured in such a facility. disadvantaged community pregnant people in the bor- made it unique, and perhaps a Comparative data examining since the early 1990s. The ough of Southwark, which at target for negative attention. different types of facilities’ sudden closure, which was the time was ranked the 14th As an exploration into the emergency response time said to have been instigated by most deprived district in Eng- accuracy of the claims made and maternal and neonatal concerns over safety, created land. Each client was assigned by King’s upon the closure outcomes are not available. quite a stir. The frustration 2 midwives at booking who of Albany Midwifery Service, This guideline acknowledges and disappointment was provided continuous prenatal, a retrospective analysis of that a person may choose to evident in the response from intrapartum and postpartum routinely collected data was undergo TOLAC in a facility the community as this unique care. The Albany midwives done by four researchers to without access to immediate and successful midwifery offered birth services in both look at the outcomes for all emergency cesarean, but service was dissolved, leaving the hospital and home setting, 2568 clients who were booked the person must be clearly fewer options for care. with an average home birth with the Albany Midwifery informed of the risks of this The Albany Midwifery rate of 43.5% during their 12 Practice from 1997 to 2009. choice, and an evaluation Practice started as the South years of service. The results were published of the person’s individual East London Midwifery Group A 2007 internal report at in Midwifery Journal in factors, their likelihood of Practice, by 6 midwives based King’s praised the outcomes 2017 and are an inspiring achieving VBAC, and their in a community center. They of the Albany Midwifery testament to the value of risk of uterine rupture is were the frst group of self-em- Service and boasted a 99% midwifery care delivered of paramount importance. ployed midwives to negotiate breastfeeding rate, an 81.4% in this caseload model to Ideally, transfer of care to a contract with the NHS and spontaneous vaginal birth vulnerable populations. a provider working in a their mission was to help ad- rate, and a low caesarean Although the people included facility capable of emergency dress disparities in health and section rate of 15.2% for the in the study were from a cesarean occurs during healthcare by providing com- service. There were various higher-risk demographic, the prenatal care, and providers munity-based, caseload model qualitative studies