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Evidence Based Clinical Practice Guideline

Evidence Based Clinical Practice Guidelines for VBAC Home Birth

Denise Doerr

Abstract
Text
CHAPTER 1

INTRODUCTION

Identification of the phenomenon of interest

Scope of the problem

In 2000, 22.9% of all births in the United States were cesarean sections. This is a 4% increase over the 1999 rate. For a point of reference, the cesarean section rate in 1970 was 5.5%. The VBAC rate in 2000 was 20.7% (Martin, 2001). Healthy People 2010 has set the goal of 18% cesarean section rate by 2010, (Healthy People 2010, November 2000). To achieve that goal, a majority of women who have had one or more cesarean must have successful VBAC deliveries for their subsequent births.

In 1980, the VBAC rate was 3.4%. In 1996, the VBAC rate peaked at 28.3%, (Martin, 2001) The increase in VBACs was achieved by encouraging and facilitating VBAC deliveries by maternity care providers. That trend has been reversed by the more restrictive guidelines that are being followed for VBAC deliveries (ACOG 1988, 1994, 1995, 1999). See the table below for a comparison of how ACOG practice quidelines have changed since 1988, and how they compare to the ACNM statement on VBAC, (ACNM, 2000).

CHANGING POSITIONS ON VBAC
POSITION ON VBACPOSITION ON VBAC WITH 2 or >
PRIORS
CONTRA-
INDICATION
MANAGE-
MENT
EPIDURAL
PITOCIN
PROSTA-
GLANDINS
WHO
ATTENDS
WHERE
ACOG 1988strongly supportive, safer than c/sec, repeat c/sec only for specific indicationsshould not be discouragedclassical incision only
(not enough evidence on multiple gestation, breech or macrosomia to contraindicate
no specific restrictions
(treat like other labors)
not restrictedphysician capable of evaluating labor and performing c/sec should be readily availablewhere c/sec can be performed within 30 minutes, as is standard for any OB patient
ACOG 1994same as abovesame as abovenon specifically listed, rate of rupture with a classical incision is noted at 12% and VBAC "should be strongly discouraged"same as aboveepidural OK.
Pitocin OK unless there is a classical incision,
no evidence to not use prostaglandin
same as abovein a hospital setting that can respond to OB emergencies
ACOG 1995same as abovesame as abovesame as 1988same as above with intermittent auscultation q15m in first stage, q5m in second stage, or EFM evaluation q15m first stage, q5m second stage, epidurals ok
Pitocin in question, conflicting evidence reported, high rates leads to increase rupture,
prostaglandin
not enough evidence
not addressedshould not be limited to large specialty hospitals,
ok at any well-
equipped
hospital that can respond to IP
emergencies
ACOG 1999not supportive,
makes
conflicting statements
"even though evidence suggests benefits outweigh risk, it is now apparent VBAC is associated with risk of uterine rupture and poor outcome, and these adverse events have led to malpractice suits"
may be considered but there is an increased risk of uterine ruptureclassical or T incision, or other transfundal surgery,
contracted pelvis,
medical or OB complication that precludes vaginal birth,
inability to perform emergency c/sec because of unavailability of surgeon, anesthesia, staff, or facility
not discussedepidurals ok,
Pitocin same as above,
prostaglandin
appears to be safe, but there are occasional reports of uterine rupture
physician immediately availableinstitutions equipped to respond to emergencies
ACNM 2000strongly supportivenot discussed"appropriate
selection"
informed consent, heightened surveillance of FHR as in high risk labornot discussedmidwives ok with arrangements for medical consult and emergency carenot discussed

These changes in guidelines and approach to VBAC delivery has come about primarily because of more recent research and editorial writings that encourage repeat cesarean section due to fear of uterine rupture, fetal and maternal mortality, and malpractice suits. (Lydon-Rochelle, et al, 2001; Phelan, 1996). ACOG admits in the 1999 guidelines that the evidence still suggests (as it did in the previous quidelines) that the benefits of VBAC outweigh the risk. But then they go on to say that what has changed or "become apparent" is that poor outcome from uterine rupture has lead to malpractice suits. They do not say that uterine rupture has increased, only that it has led to malpractice suits. In this one conflicting statement is the heart of the controversy. ACOG is suggesting in essence that we overlook the evidence based guidelines. They are admitting the studies continue to support VBAC ("benefits outweigh the risks"). They are changing the guidelines because it is "now apparent" that rupture leads to malpractice suits. What has changed is not the evidence. It has always been apparent that there is a risk of uterine rupture with VBAC. The change is due to the fact that now it is apparent that the cases of rupture have led to an increase in malpractice suits (ACOG, 1999).


Cesareans result in more pain, debility and longer recovery period than normal spontaneous vaginal delivery. Up to 30% of women who have a cesarean acquire a postpartum infection, which leads to higher rate of maternal morbidity and longer hospitalization (Henderson, 1995). The maternal death rate is twice as high for cesarean as for vaginal delivery (Greene 2001). Cesareans increase the risk of complications which may include hemorrhage, injury to bowels, ureter and bladder, chronic pain, bowel difficulties, infertility, miscarriage, ectopic pregnancy, placental abruption, and placenta previa (MacCorkle 1998). In a Swiss study of 29,000 women with prior cesareans, repeat cesarean section led to 3 times the number of hysterectomies, and double the number of blood clots (Rageth 1999).

Studies have shown that the rate of cesarean section is up to 3 times greater in hospital births than in home births (Mehl, 1977, Anderson, 1999, Olsen, 1997). Healthy People 2010 has set a goal to lower the nationwide rate of cesarean section to 15% by the year 2010 (Healthy People 2010, 2000). Home birth is a unique and controversial way to increase the availability and success of VBAC, and therefore to lower the rate of cesarean section. The evidence suggests that instead of discouraging VBAC which increases the rate of cesarean, ACOG should be encouraging many VBAC women to birth at home with a trained attendant where dangerous interventions will not be available to them and they will have a better chance of attaining a normal spontaneous vaginal delivery.

Pregnant women choose midwifery care because it is personal, safe, and cost-effective. VBAC delivery is still the safest and best option for a majority of pregnant women who have had a previous cesarean. Fear of malpractice suits, restrictive protocols, and medical advise has led to a downward trend in the number of VBACs being attempted and completed in hospitals. Many women will look to midwives, as the guardians of normal birth, to help them achieve their goal of having a VBAC birth, and some of these births will take place at home. Home birth midwives caring for VBAC clients need carefully researched evidence based guidelines to provide the safest care possible for these women. The purpose of this paper is to review the research to determine what the best care practices are for VBAC births at home.

Gaps between current practice and evidence based practice
The trend in current practice is toward discouraging VBAC and encouraging repeat cesarean section because of research that shows a dramatic increase in uterine rupture with VBACs (Lydon-Rochelle). The research actually shows the significant increase of rupture is due to the management of VBACs in the hospital, specifically labor induction and augmentation. The gap between what the research says, i.e. don't induce or augment VBACs, and what the current practice is, i.e. do more repeat cesareans to reduce rate of uterine rupture, is a wide one. To bridge that gap, we need to go back to the previous VBAC practice guidelines that encouraged and facilitated VBAC (ACOG 1988, 1994,1995). These guidelines are in line with what home birth attendants have been doing all along to facilitate normal birth. The risk screening done for VBAC is not much different than the risk screening done for home birth. With the addition of a few items added to risk screening and practice guidelines that home birth attendants have been using all along, home birth VBAC is a relatively safe alternative based on the current evidence.

Theoretical and operational definition of terms
VBAC (vaginal birth after cesarean) is defined as a vaginal birth that occurs at some point after a woman has had one or more previous births by cesarean section. The operational definition assumes that the woman has one or more scars on her uterus from an incision to remove a baby through the abdomen.

The theoretical definition of home birth is a birth that occurs in the mother's place of residence. The operational definition of home birth expands on that definition to include birth that takes place in an environment that the mother feels at home in, which could be the home of someone else, a motel, or even outside in a private place. It does not take place in a hospital or a birth center.

Assumptions and philosophical approach
The midwifery philosophical approach to pregnancy and birth is to focus on the normalcy of these events. Midwives believe that women's bodies are "well designed for birth" and try to avoid interfering with the natural processes of pregnancy and birth (Rooks, 1997). This is in contrast to the medical model of birth that focuses on the uterus and fetus, potential for pathology, tests, procedures, and interventions to the extent that one out of every four women undergoes surgical incision to give birth (Rooks, 1997). Midwives focus on the whole woman, not just her uterus. The psychological and emotional well being of her clients are just as important as her physical well-being. The environment the client lives in, her cultural and spiritual influences, and the environment of the birth setting are all considered in midwifery care. Midwives often refer to the women they care for as clients instead of patients to make the distinction from a person seeking health care for an illness, and a normal, healthy, pregnant woman seeking health care to safeguard the natural processes of pregnancy and birth. The rights and beliefs of the client are honored. The ACNM philosophy midwifery states that " every individual has the right to safe, satisfying health care, with respect for human dignity and cultural variation., " and "midwifery care is focused on the needs of the individual and family for physical care, emotional and social support, and active involvement," and "advocates nonintervention in normal processes" (ACNM, 1989).

When the environment of birth is accepted as an important consideration, and when a client's right of self-determination is honored, home birth is regarded as a valid and safe alternative for certain women choosing it. When risk factors are weighed using applicable evidence, VBAC is also a valid and safe choice for some women. Since midwifery philosophy is to be noninterventive, we can make the following assertions:
1) Home birth is safer for some women because interventions are less likely at home (Mehl, 1977).
2) VBAC is safer at home because interventions are less likely to occur (Mehl, 1977), and it is the interventions that make VBAC higher risk (Lydon-Rochelle).

Limitations of the state of the science in this area
The gold standard of comparing the safety of two approaches to health care is a randomized clinical trial. This is not a possible way to study home compared to hospital birth, because few women would be willing to give birth in a certain place on the basis of a random assignment. Also, only low risk women would be used in such a study so a very large sample would be needed to calculate incidence of poor outcome (Rooks, 1997).

Another limitation of the science is that home birth is not a standardized product; the safety will vary with the conditions. The following conditions are generally agreed upon to be necessary for home birth to be safe:
1) Risk screening so only healthy women with normal pregnancies are eligible for home birth.
2) Attendance by trained midwives or physicians.
3) Ability to transport to a hospital rapidly.
4) Good communication and working relationship between midwives and collaborating physicians.
Conclusions from a study of one home birth practice cannot be assumed to extend to others that do not maintain the same standards and conditions. Several types of data are used to study home birth, such as birth certificate data, data from home birth practices, and mortality reviews. Each type of study has strengths and limitations (Rooks, 1997).

VBAC has been studied extensively. The limitations of these studies are that none of them consider the birth setting as a confounding variable. There is no home birth VBAC versus hospital birth VBAC study. Indeed, there are no home birth VBAC studies to date. It is difficult to analyze outcome of births and relate them to place of birth even in a carefully conducted study, because outcome can be determined by many variables besides place of birth and VBAC risks. The numbers of women having home births is low, and the numbers of women having home birth VBAC is much lower still, making it difficult to have a sample large enough to achieve adequate statistical power. Many practitioners who attend home birth VBAC would be unwilling to participate in a study because they practice outside the law, and may not even keep track of outcome, much less be willing to make their outcomes available for studies. All these reasons put severe limitations of the state of the science in this area of concern.


CHAPTER 2
The study was conducted from a Washington State Birth Events Records Database on deliveries between 1987-1996. The data was narrowed down to 20,095 subjects for analysis using maternal and infant hospital discharge data, and birth certificate data. Variables were examined for possible effects and considered to be confounding if their inclusion changed the relative risk for uterine rupture by 10% or more. The variables examined were; maternal age, race, marital status, smoking status, diabetes, chronic hypertension, preeclampsia, herpes, interval between births, payer, hospital level, infant birth weight, gestational age, breech presentation, and placenta previa. No variables were found to change the relative risk for uterine rupture. The results are shown below.

RATE OF UTERINE RUPTURE
subset of women with one previous cesarean
rate per 1000
repeat cesarean, no labor
1.6
spontaneous onset of labor
5.2
labor induced by means other than prostaglandins
7.7
labor induced with prostaglandins
24.5

Final data from the CDC for the year 2000 (the most recent year available) reports that the rate of cesarean deliveries rose for the fourth consecutive year to nearly 23%. The cesarean rate declined steadily between 1989 and 1996, but has risen 11% since 1996, and is now the highest since 1989. Between 1999 and 2000, the primary cesarean rate was up 4% and the VBAC rate dropped 12%. There were 4,058,814 births in the United States in 2000 (National Center for Health Statistics, 2002). Twenty-three percent of this number is 933,527 women. Many of these women will choose to have a vaginal birth the next time they become pregnant, or even after they have had two or more cesareans. Some of these women will choose, for varying reasons, to have this VBAC birth at home. The research I have reviewed shows that home birth is a safe alternative for certain women, and that VBAC is a safe alternative for certain women. The problem addressed by this paper is to determine which women are candidates for VBAC home birth, and under what circumstances.

Criteria for safe* home birth (including VBAC home birth):

1. Risk screening
Careful risk screening is done for every client prenatally, to determine if the client is a candidate for home birth. The first criteria for risk screening is that the client is self-selected. Ninety-nine percent of women in the U.S. give birth in hospitals. Many people are not even aware home birth is an option, and many people who do know about it believe it is dangerous. Women considering home birth are often discouraged from persuing this option, not only from medical personnel, but also from family and friends. Women who persist in their choice of home birth are indicating a certain psychological readiness which is important for the success of this option. Through self-selection, they exhibit an ability to take responsibility for themselves and their birth. Risk screening is an ongoing process, throughout antepartum, intrapartum, and postpartum, and for the newborn. At any point, the client(s) may be screened out of home birth and transferred to a hospital. Determining eligibility for VBAC home birth entails further information about the previous surgery, the scar, and the reasons for the cesarean. Screening intrapartum for VBAC is the same as for any client, with extra vigilance concerning fetal heart tones, and with awareness of signs and symptoms of uterine rupture. (see Appendix A VBAC Criteria, Appendix C Home Birth Criteria, Appendix E Indications for Referral and/or Transfer, Appendix F Practice Guidelines)
2. Trained birth attendant
It has been shown that having a trained birth attendant is an integral part of safe home birth (Schramm, 1987). Certified Nurse Midwives and Certified Midwives who wish to attend home births need to undergo extra training if they have no experience attending home births. For example, handling emergencies is sometimes different at home than at a hospital, because of personnel and equipment available. Some states have licensed midwives who have special training for home birth. Many midwives who attend home birth are direct-entry midwives who have received training through the time-honored method of apprenticeship. What is considered adequate training for a home birth attendant is beyond the scope of this paper.
3. Medical consult and emergency hospital back-up available
A certain percentage of home birth clients will be transferred to a hospital for various reasons. For the transfer to be smooth and efficient (and therefore entail less time and risk) medical consult must be a part of the birth attendant's usual procedure, along with a reasonably close hospital. There is considerable debate about how close to a hospital the birth should be. Within 30 minutes is used in the ACNM Insurance Service exclusions for coverage, but in many rural areas this is not possible (ACNM Insurance Service, 2001).

The problem addressed by this paper is; what specific guidelines are needed to ensure safety in practice before, during and after a home birth, and what added guidelines are needed, if any, when that home birth is a VBAC?

*The word "safe" refers to relative safety. It is necessary to understand that birth anywhere, at any time, has risks involved for mother and baby. "Safe" home birth is not meant to imply that there are no risks, only that the risks are no greater than in a hospital, or that the risks are at an acceptable level. Having a baby in a hospital does not guarantee safety, and there are iatrogenic risks involved as well.

Method of development

Process Used

An extensive review of literature was conducted to gather information specifically on home birth and VBAC, and practice quidelines currently in use for both of these options. Midwifery and obstetric textbooks were used, as well as medical journals, ACNM publications, ACOG publications, and local hospital written protocols for VBAC. An ACNM online home birth discussion (chat room) was also utilized to obtain current home birth and VBAC protocols in use by CNMs around the country (V. Lott, personal communication, Septermber 12, 2002). An internet search using the key words home birth and VBAC was used on Medline, CINHAL, and the Cochrane Library, and over 200 journal article titles and abstracts were retrieved, considered, and narrowed down to 22 articles. The full texts were obtained through the Gundersen Lutheran Hospital Medical Library in LaCrosse, Wisconsin. This information was reviewed to determine a base of knowledge about the relative safety of home birth and of VBAC, and what criteria are necessary to ensure this relative safety in terms of clinical decision making.

Evidence considered

Table 1 RETROSPECTIVE HOME BIRTH STUDIES

STUDY
GRADE OF EVIDENCE
STUDY DESIGN
STATISTICS REPORTED
CONCLUSIONS/ OPINIONS
Outcomes of 11,788 Planned Home Births by Certified Nurse Midwives
(Anderson, 1995)
D
Retrospective cohort survey
N=11,788 home births
intrapartum/neonatal mortality =2/1000 (0.9/1000 excluding congenital anomalies)
transfer=7.4%
Planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.
The Cost-Effectiveness of Home Birth (Anderson, 1999)
D
Retrospective cohort survey
N=11,592 hospital births and 11,788 home births
mean hospital birth cost in 1991= $5382
mean home birth cost in 1991=$1844
overall neonatal mortality for home birth= 1.3/1000
overall neonatal mortality for hospital births=2.2/1000
Home births offer lower rates of neonatal mortality and cesarean section, and a savings of up to 76% over hospital births
Home birth in the United States, 1989-1992 (Declercq, 1995)
D
Retrospective longitudinal study
N=82,210 home births
CNM attended=12%
physician attended=20%
other midwives attended=30.5%
other attended=37%
Outcomes of newborns born at home compared favorably to the national average dring the same period. Several findings varied considerably by race or ethnicity of the mother.
The Safety of Home Birth, The Farm Study,
(Durand, 1992)
D
Retrospective comparative study
N=1707 home births
N=14,033 hospital births
overall home birth mortality rate (intrapartum and neonatal)=8.8/1000
The mortality rate is higher than home birth rates from other studies. It includes a very different population; breech, twins, high parity, hospital transfers,and other complicated deliveries not normally attempted at home. The rate compares with the overall rate for the U.S.
Home birth with Certified Nurse Midwives, (Jackson, 1995)
D
Meta-analysis retrospective overview
International literature documents the saftey of home birth.
Outcomes of elective home births, (Mehl,1977)
D
Retrospective matched population comparative study
N=1,046 home births
N=1,046 hospital births
neonatal and perinatal mortality rates for home and hospital were statistically the same
Incidence of all interventions studied was lower in the home birth cohort. Home birth is as safe or safer than hospital birth.
Meta-analysis of the safety of home birth, (Olsen, 1997)
D
Meta-analysis retrospective
N=24,092
perinatal mortality was not significantly different between the two groups (OR= 0.87, 95%CI 0.54-1.4)
Home birth is an acceptable alternative to hospital birth for selected women, and leads to reduced medical interventions.
Outcome of planned home births in Washington State: 1989-1996, (Pang, 2002)
D
Retrospective analysis of birth registry
N=6133 home births, neonatal mortality= 3.3/1000
N=10,543 hospital births, neonatal mortality=1.7/1000
Planned home birth had greater infant and maternal risks than hospital births.
Neonatal mortality in Missouri home births,
(Schramm, 1987)
D
Retrospective analysis of birth attendants' charts
N=4,054
neonatal mortality=5.5/1000, neonatal mortality with trained attendants= 1.6/1000
Shows that skilled attendants at planned home birth improves outcome.
Place of birth and perinatal mortality,
(Tew, 1985)
D
Retrospective analysis of Bristish sample surveys of births
N=4,394 hospital low risk
N=3,094 clinic and home low risk
perinatal mortality for hospital births=8/1000
perinatal mortality for home/clinic births=3.9/1000 (p<0.05)
Obstetrical practices in hospitals make birth less safe than home births with no intervention.


Table 2 RETROSPECTIVE VBAC STUDIES

STUDY
GRADE OF EVIDENCE
STUDY DESIGN
STATISTICS
CONCLUSIONS/
OPINIONS
Vaginal births after Ceasarean (Appleton, 2000)
D
retrospective cohort study in Australia
N=234,015 births
9.2% previous cesareans of which 5419 or 25.3% had a successful VBAC
uterine rupture rate=0.3%
perinatal death rate=0.5%
maternal mortality
Incidence of uterine rupture is low and appears to be associated with better outcome than ruupture of an unscarred uterus.
Safety and efficacy of attempted vaginal birth after cesarean beyond the estimated date of delivery, (Callahan, 1999)
D
retrospective matched control analysis
N=90 in each group
rate of successful VBAC=65.6%
rate of vaginal delivery among women with no prior cesarean=94.4%
(P<.0001)
No maternal mortality
No neonatal mortality
1 uterine rupture
Post-dates does not alter the efficacy or safety of trial of labor.
Cost-effectiveness of trial of labor after previous cesarean, (Chung, 2001)
D
retrospective data analysis of cost of procedures and outcomes using a hypothetical modelprobablity <65% of vaginal delivery=repeat cesarean is more cost-effective
probability >75% of vaginal delivery=VBAC is cost effective
VBAC is cost effective in certain situations when success is more likely (ie one prior cesarean for a non-repeating cause), but more research is needed to determine likelihood of VBAC success.
Uterine rupture in pregnancy reviewed (Gardeil, 1994)
D
retrospective cohort
study
N=65,488 births
15 cases of uterine rupture (1/4366) overall, 2 in unscarred uteri, 13 in VBACs, 13 of the 15 cases had pitocin induction or augmentation
This review highlights the risk of uterine ruptuire when pitocin is administered to a patient with a scarred uterus.
Risk of uterine rupture among women with a prior cesearan delivery (Lydon-Rochelle, 2001)
D
population based retrospective cohort analysisN=20,095
compared to women with repeaat cesarean w/o labor, uterine rupture was more likely among women with spontaneous onset of labor (relative risk,3.3; confidence interval 95%), induction w/o prostaglandins (relative risk 4.9; confidence interval 95%), induction with prostaglandins (relative risk 15.6; confidence interval 95%)
For women with one prior cesarean the risk of uterine rupture is higher with labor induction, and induction with prostaglandins confers the highest risk.
Rupture of cesarean-scarred uterus: a community hospital experience, (Poma, 2000)
D
retrospective data analysis from 1988-1997 at University of Ill. Medical Centerdata of c/sec and VBAC rate analysized before and after changes in strategy to reduce rate of c/sec

total c/sec rate reduced from 24.3% to 17.9% (p<0.0001)
primary c/sec rate reduced from 14.9% to 10.3% (p<0.0001)
repeat c/sec rate reduced from 9.4% to 7.6% (p<0.0001)
VBAC rate increased from 13.0 to 28.6 (p<0.0001)
no change in the rate of uterine rupture
Increasing the rate of VBACs and decreasing the rate of cesarean does not increase the risk of uterine rupture.
Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies, (Smith, 2002)
D
Population-based retrospective cohort study of data from Scottish Morbidity RecordsN=15,515 trial of labor, periantal death 1.29/1000 (95% CI, 7.9-19.1)
N=9014 planned repeat c/sec, perinatal death 0.1/1000
N=137,160 nulliparous, perinatal death 1.0/1000
(OR 1.3, 95% CI, 0.8-2.1)
N=151549 multiparous ,
perinatal death 0.59/1000 (OR 2.2, 95% CI, 1.3-3.5)
Risk of perinatal death associated with trial of labor is low, but significantly higher than that associated with planned repeat cesarean.
Vaginal birth after cesarean; an appraisal of fetal risk, (Socol, 1999)
D
Retrospective data analysis study comparing 4 cohortsN=1677 successful VBAC
N= 405 unsuccessful VBAC
N=920 elect repeat cesarean
N=22,863 NSVD, no prior cesarean
Apgar <7 (5 min) with VBAC attempt=2.4%, with repeat c/sec=2.1% (OR 1.14)
umbilical artery pH<7 with VBAC attempt=1.2%, with repeat c/sec=1.3%
(OR 1.36)
VBAC poses a low level of fetal risk.
Maternal and neonatal outcomes after uterine rupture in labor, (Yap, 2001)
D
Retrospective chart review of uterine rupture between 1976-1998N=38,027
rate of uterine rupture=1.8/1000
maternal morbidity=0
perinatal morbidity=
0.05/1000
VBAC presents a relatively small risk of uterine rupture but uterine rupture does not result in major maternal or neonatal mortality or morbidity.
Obstetric uterine rupture in north Jordan, (Ziadeh, 1996)
D
Retrospective chart review of cases of uterine rupture between 1989-1994N=37
maternal mortality=0
perinatal mortallity=46%
High incidence of uterine rupture is attributed to lack of prenatal care, high risk labor out of hospital, and prolonged labor with 2 or more prior cesareans. The main cause of rupture was obstructed labor by malpresentation.

Table 3 PROSPECTIVE STUDIES

STUDY
GRADE OF EVIDENCE
STUDY DESIGN
SAMPLE SIZE AND
DESCRIPTION
RESEARCH
PROCEDURE
MEASURES USED
RELIABILITY AND VALIDITY
STATISTICSSTUDY RESULTS AND MIDWIFERY PERSPECTIVE
Outcome of intended home births in nurse-
midwifery practice, a
a prospective descriptive study,(Murphy, 1998)
D
Prospective
Descriptive
N=1404 women intending home birth29 CNM practices were recruited to follow their home birth clients and gather the dataeligibility for home birth, transfer rate, fetal and neonatal mortality,
validity and reliability was established
6% terminated miscarried or changed plans,
7.4% became ineligible for home birth AP, 8.3% were transferred IP,
0.8% were transferred PP
1.1% infants were transferred after birth,
2.5/1000=
overall fetal and neonatal mortality for intended home births,
1.6/1000=
fetal and neonatal mortality for those delivered at home
Home birth can have good outcomes with qualified attendants, and within a system that facilitates transfer to hospital when necessary.
Is vaginal birth after cesarean safe? Experience at a community hospital,
(Blanchette, 2001)
D
a 4-year prospective cohort study with outcome comparisonsN=1481 women with prior cesareans
n=727 women who elected repeat cesareans
n=754 women who attempted trial of labor
(TOL)
Prospective chart review between 1996-1999 on women with prior cesareans were subdivided into TOL and repeat cesarean, the TOL cohort was then subdivided into successful and failed VBAC.
Maternal and fetal complications were reviewed and compared.
Analysis of variance (parametric and nonparametric) were used, P<.05,
measures used: rate of uterine rupture, Apgar scores, blood loss, birth weight, induction , augmentation, and others
neonatal mortality for successful VBAC=0,
for failed VBAC =2 (due to uterine rupture)
for repeat cesarean=0
58.3% of uterine rupture underwent induction,
22% of successful VBAC underwent induction (P=.003)
epidural rate was significantly higher in the successful VBAC group (P=.004)
1.6% uterine rupture (12 cases)
11 of the 12 were induced or augmented or both
Trial of labor after cesarean is safe provided induction is not used




Criteria established for effectiveness

This criteria has been discussed above. For risk screening criteria and VBAC home birth eligibility, see Appendixes A and C. For home birth clinical practice guidelines, including VBAC home birth, see appendix F. As already noted, criteria for what constitutes a "trained home birth attendant" is controversial and debate continues. General opinion is that a qualified, trained birth attendant has gone through a standardized education or evaluation process, such as a physician, a CNM, CM, CPM, or LM.

Clinical perspective

The research reviewed for this paper was conducted by physicians, nurse-midwives, and nurses. Some of the literature and client education materials were written by direct entry midwives, licensed midwives, and lay people as well. Therefore the clinical perspective is interdisciplinary because evidence is based on medicine, nursing, midwifery, and lay perspectives.

Population of interest

Home birth is chosen by approximately 1% of the birthing population. In 2000, there were 3,048 home births attended by certified nurse-midwives, and 9,501 home births attended by other midwives to total 12,549 home births reported by the Center for Disease Prevention (National Center for Health Statistics, 2002). As already noted, the number of women undergoing cesarean section in 2000 is 933,527. The VBAC rate increased 50% between the years 1989 to 1996, (National Center for Health Statistics, 2002). The VBAC rate declined 12% from the years 1999 to 2000, and declined 27 % from the years 1996 to 2000. There are no statistics on home birth VBAC at this time. The population of interest is essentially any woman who has had a cesarean section and is interested in home birth and in VBAC.

The other population of interest for this EBG are the home birth attendants. Unfortunately, there are no statistics at this time that indicate how many birth attendants are actually offering home birth VBAC services. From midwifery chat room discussions, there is evidence that home birth VBAC is being done by a certain number of midwives, but there is no formal system to collect the information on numbers. This is an area of research that needs to be done in the future.

Decision Support

Synthesis of evidence

1. Research supports that home birth is safe for certain women in specific situations.

2. Risk screening is done to determine which clients are appropriate home birth candidates throughout the childbearing cycle.

3. Risk screening information and procedure specific for VBAC clients ensures that an acceptable level of safety is achieved for these clients.

4. VBAC birth should not be induced or augmented with prostaglandins or Pitocin. If a clinical decision is made that one of these things are necessary, then the home birth candidate would be screened out to a hospital facility. There are methods of induction and augmentation using herbal remedies that may be applied in home births, but at this time there is no evidence of their safety with VBAC clients.

5. Adequately trained personnel is essential for safe home birth for all clients.

6. Appropriate equipment and emergency supplies must be available at the home birth and during prenatal care.

7. Reasonably timed access to a medical facility is necessary.

8. Medical consult arranged proactively by the birth attendant or the client, to be available when needed, is necessary.

9. Carefully educated informed consent must be obtained from the client and her partner, for home birth, for VBAC, and the combination. (see Appendix B and D)


Summary statement of findings

Twenty-three per cent of all pregnant women will undergo a cesarean section (National Vital Statistics,2002). Sixty-five percent of these women could most likely achieve a vaginal delivery in future pregnancies (Yap, 2001). An estimated 1% of these women will choose home birth, and will be acceptable candidates for home birth given that the criteria for VBAC home birth discussed above are met. There is risk involved in having a home birth, and there is risk involved in having a VBAC. Likewise there is risk involved in having a hospital birth, and there is risk involved in having a repeat cesarean. Educating clients about what the risks are gives them the freedom to choose which set of risks is acceptable to them with a clear understanding that no option is risk free, but that certain options are relatively safer than others, and that the relative acceptable level of safety may be different from the medical, midwifery and personal perspective. Discussing the safety issues and educating the parents about risks involved in various options for childbirth allows the parents to take a certain amount of responsibility for their birth and their child. This responsibility is shared with the birth attendant. Informed consent facilitates this sharing of responsibility (see Appendix B and D). This is a very different approach from that of limiting options by failing to educate clients about all the various options. This failure may occur because the birth attendant is unaware of the statistics, or has a bias about a particular option and chooses not to offer it.

Outline of EB-CPG clinical algorithm

VBAC client self-selects as a home birth candidate.
Does client meet VBAC criteria, and has she signed a VBAC informed consent?
(see Appendix A & B)
no---------> refer to hospital care provider
yes-------->Does client meet home birth criteria and has she signed a home birth informed consent?
(see Appendix C & D)
no---------> refer to hospital care provider
yes---------> accept as home birth VBAC client

Does client develop any risk factors or contraindications to home birth during her AP, IP, or PP care?
(see Appendix E & F)
no-----------> continue with vaginal birth and home care
yes----------> consult with physician and/or transfer to hospital care depending on situation


Appendix A VBAC criteria
Appendix B VBAC informed consent form
Appendix C Home birth criteria
Appendix D Home birth informed consent form
Appendix E Indications for referral or transfer
Appendix F Practice guidelines



Evaluation/Measurement strategy and reevaluation plan

The rate of primary cesarean section has remained stable at around 16% since the 1980s, but the rate of repeat cesarean and VBAC has fluctuated based on medical opinion and media publications. In the early 1990's, there were many articles published supporting the safety of VBAC birth and of home birth. During this time, concerted effort was made to increase the rate of successful VBACs. Physicians and midwives were encouraging women with previous cesarean delivery to undergo trial of labor, and managing VBAC births as if they were low risk. Interventions, such as induction and augmentation of labor became acceptable and the rate of uterine rupture went up. Because of this, new research articles were published demonstrating the risk of uterine rupture with trial of labor. Unfortunately, the media and ACOG have misinterpreted this new data as meaning that trial of labor is an option that carries unreasonable risk. In fact, the research reviewed in this paper demonstrates that trial of labor and VBAC are as safe as they were previously when managed appropriately and when not augmented or induced. The review of literature regarding home birth overwhelmingly demonstrates that home birth is a safe alternative for healthy women with a trained birth attendant and a medical back-up plan. VBAC at home is therefore a relatively safe alternative for some women. This EB-CPG is based on the research analysis done in this paper. Since there is no specific research on VBAC home birth, this is an area that needs further investigation. New research on trial of labor, VBAC, and home birth will be reviewed and analysed on an annual basis and that data will be taken into consideration to revise and update this EB-CPG.

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Appendix A
VBAC Home Birth Eligibility Criteria
HOME BIRTH AGREEMENT

Most births proceed normally without any problems and require only support and guidance. There are a small proportion of births in which serious complications may develop. If such complications should occur, you or your baby might be at greater risk because of your decision to birth at home. There are also risks involved in birthing your baby in a hospital. If you opt for the set of risks involved in birthing at home, I will discuss with you what those risks are and how they are usually handled.
Prenatal care, excellent nutrition, and careful monitoring during labor greatly reduce the chance that such complications will occur. However, I CANNOT GUARANTEE THE OUTCOME OF YOUR BIRTH. I can only make judgments and give care based on my training and experience. I CAN GUARANTEE that I will use 100% of my skills and care, heart and hands, to help you and your baby pass safely through the birth process.

I/We have read the preceding Informed Choice Agreement, and fully understand the risks that may be involved with choosing to give birth at home. I/We hereby request that Denise Doerr, CNM, be present at our birth to act as our midwife.

Date ---------------------------------------------------------------

Signed ---------------------------------------------------

---------------------------------------------------



Appendix E Indications for referral or transfer
OPEN DOOR MIDWIFERY
INDICATIONS FOR REFERRAL OR TRANSFER OF CARE

I. The following conditions existing prior to the present pregnancy may necessitate referral to a physician for prenatal care and delivery.


congenital abnormalities which may effect childbirth

II. The following conditions developing during the present pregnancy may necessitate referral to a physician.


parents ill-prepared for home birth

III. The following conditions developing during labor may necessitate transfer to a hospital, and/or referral to a physician.


desire of mother for transfer for any reason

IV. The following conditions developing during the immediate postpartum period may necessitate transfer to a hospital and/or referral to a physician.


respiratory distress

cardiac irregularities

weight less than 2500 grams (5 & 1/2 pounds)

congenital abnormalities

Apgar <7 at 5 minutes

prematurity, dysmaturity, or postmaturity

rectal temperature > 101 degrees Farenheit

any other problems requiring hospital care in the opinion of the attendants

I/We have read, discussed, and understand the above:

signed__________________________________________________________________________________________________

signed__________________________________________________________________________________________________

date ------------------------------------------------------

Appendix F Practice guidelines


Clinical Guidelines for Practice


A. Mission statement B. Philosophy
1. Pregnancy, childbirth, and menopause are normal life events. These events are designed as healthy processes.
2. Although the above listed life events are normal healthy processes, the potential for women and newborns to develop pathology does exist-just as this potential exists for all individuals.
3. The standards of care for OPEN DOOR MIDWIFERY are those set forth by the American College of Nurse-Midwives as the minimum standards for midwifery practice.
4. Midwives are experts in the care of the essentially healthy woman and newborn. Physicians have additional expertise in the care of individuals with pathological conditions. Each health care discipline provides its own unique and valuable body of knowledge. Therefore, women and newborns are best served when midwives and other members of the health care system work in an interdisciplinary manner. Consult, collaboration, and referral when indicated, are important goals.
5. Women have the right, and responsibility, to choose among the available health care options-within the realm of safety. These choices include, but are not limited to, choice of health care provider, choice of birth location, and the choice to accept or decline various provider recommendations.
6. The fetus/neonate is completely dependent on the parents and health care providers for health care decisions. Unable to speak for him/herself, the fetus/neonate has the right to respectful consideration before any health care decision is made.

C. Goals
1. To provide health care for essentially healthy women and their newborns.
2. To provide objective, complete informed consent opportunities to clients. This informed consent should include information about community standards of practice, current available research evidence, alternative options, and potential benefits and risks of each. 3. To empower women to take responsibility for their health through wellness education, risk screening, and complete informed consent. Women will be strongly encouraged to participate in the decision making process regarding their own health, utilizing the midwife as advisor. The woman’s preferences will be documented through written informed consent statements when applicable.
4. To educate the public and private sectors of the community about midwifery care.
5. To promote and facilitate mutually respectful interaction among all members of the health care system. Special emphasis will be placed on interdisciplinary practice, where each health care provider contributes his or her unique body of knowledge and skill.

D. Definition of Terms
1. Birth options 2. Client 3. Collaboration 4. Consult 5. Essentially healthy woman and newborn 6. Evidenced-based practice 7. Holistic 8. Informed Consent 9. Interdisciplinary 10. Midwife 11. Normal 12. Practice guidelines 13. Physician 14. Referral 15 Transfer
E. Interpretation and application of practice guidelines
1. Each practice guideline includes a variety of management options, to be applied individually on the basis of clinical need.
2. Community standards of care are recommended first among health care options. Women, however, are unique individuals with diverse values and beliefs. Therefore, alternative options will also be outlined.
3. Practice guidelines will be reviewed and updated annually.

INTIAL ACCEPTANCE FOR CARE

A. First trimester (0-12 weeks) B. Second trimester (13-28 weeks) C. Third trimester (28-40+ weeks) D. Distance to the hospital (for planned homebirth)

ANTEPARTUM GENERAL GUIDELINES

Initial OB visit 1. Medical, obstetrical, family and social history
2. Head to toe physical exam
3. Establishes accurate EDD based on a correlation of:
a. LMP, LNMP
b. Client’s known menstrual pattern / cycle length
c. Known or estimated date of conception
d. Early ultrasound if LMP is uncertain or cycles are irregular
e. Quickening
f. Uterine size
4. Offers / recommends labs:
a. Pap smear (if last pap >12 months ago or previous abnormal)
b. CBC with platelets
c. Blood type, Rh & antibody screen
d. Rubella immunity status
e. Urine pregnancy test
f. Urine analysis, culture if >8,000 WBC
g. GC / Chlamydia culture
h. HIV
i. HBsAG
j. VDRL or RPR
5. Offers additional labs as needed:
a. HSV culture
b. HgB electrophoresis if at risk for hemoglobinopathies
c. Sickle cell screen if at risk
d. Serum ferritin if at risk for reduced iron stores
e. Wet prep if symptomatic or vaginal discharge is present
f. Varicella titer, if history unknown
6. Provides nutritional counseling:
a. Collects & discusses a one-week nutrition diary
b. Initiates prenatal multi-vitamin, as indicated
c. Initiates prenatal iron supplement, as indicated
7. Provides educational counseling:
a. Abuse prevention (physical, sexual, emotional)
b. Activity and rest
c. Financial needs / referral for help, as indicated
d. Personal hygiene
e. Pregnancy warning signs and emergency care
f. Substance abuse
g. Teratogen exposure / avoidance of exposure
8. Formulates “List of Concerns” based on assessment of risk factors derived from H & P, “Prenatal Risk Assessment for Homebirth,” and lab test results.
9. a. Practice guidelines, including screening criteria
b. Prenatal care schedule
c. Informed Consent Statement for Homebirth, if applicable
d. Financial policies
e. Responsibilities of client & midwife
f. Role of consulting physician
g. Collaborative care / transfer of care criteria

Return OB visit
1. Schedule
a. Up to 28 weeks: every 3-4 weeks
b. From 28-36 weeks: every 2 weeks
c. From 36 weeks to birth: every week
d. More frequent visits as necessary
2. Elicit interim history
a. Pregnancy warning signs
b. Pregnancy discomforts
c. Fetal movement
d. Nutrition
e. Activity
f. Medications and / or herbs used
g. Client concerns
h. Family dynamics
3. Physical assessment
a. BP, weight, urine dip for protein / glucose
b. Fundal height & Leopold’s maneuver
c. FHT per doppler or fetascope
d. Presentation after 28 weeks gestation
e. Discuss and offer MSAFP at 16-18 weeks
f. Discuss and offer at 26-28 weeks
1) One hour glucose screen (GCT) 2) Follow-up three hour glucose test (GTT) as indicated
3) Hemoglobin and antibody screen
4) Rhogam, if indicated
g. Discuss and offer at 36 weeks
1) GBS culture
2) Fetal kick counts
3) Auscultated acceleration testing (3)
h. Ongoing risk assessment & testing
1) Refer for genetic counseling, as indicated
2) Update risk scoring and management plan prn
3) Consult physician, as indicated
4) Ultrasound, NST, BPP as needed
5) Additional labwork, as indicated 4. Home visits (for home birth clients)
a. One home visit in the first trimester to assess accessibility of home, hygiene, utilities, and travel route
b. One home visit at 34-36 weeks to assess birth area preparation
5. Provide educational counseling:
a. Nutrition, activity, rest, sexuality
b. Pregnancy warning signs and emergency measures
c. CNM / physician / client responsibilities
d. Childbirth preparation & comfort measures
e. Breastfeeding
f. Community resources
g. Signs of labor / how & when to call midwife
h. Newborn care
. . . . . . .