Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine

Objective: The American College of Obstetricians and Gynecologists (ACOG) revised its practice bulletin on vaginal birth after Cesarean (VBAC) in October 1998 and July 1999 to require the presence of a surgeon, anesthesiologist and operating personnel throughout the trial of labor for patients with prior Cesarean. This study measures the change in VBAC rates from 1998 to 2001 and examines possible reasons for this change.

Study design: We examined birth certificate and hospital data in the State of Maine from 1998 to 2001. Hospital-specific rates for primary Cesareans, total Cesareans, repeat Cesareans and vaginal deliveries after previous Cesarean were obtained. Additionally, we surveyed current obstetric-care providers in Maine regarding reasons for change in VBAC rates at their institutions.

Results: VBAC rates declined by over 50% from 30.1 to 13.1%. The total Cesarean rate climbed from 19.4 to 24.0%. The most commonly reported reason for decrease in VBAC varied depending on whether a practitioner's hospital met ACOG guidelines.

Conclusion: A marked decline in VBAC occurred after the change in ACOG vaginal birth after Cesarean policy. Multiple factors have contributed to this decline, including patients refusing VBAC after counseling and inability of institutions to meet ACOG guidelines.     

Vaginal birth after Cesarean rates are declining rapidly in the rural state of Maine.

OBJECTIVE: The American College of Obstetricians and Gynecologists (ACOG) revised its practice bulletin on vaginal birth after Cesarean (VBAC) in October 1998 and July 1999 to require the presence of a surgeon, anesthesiologist and operating personnel throughout the trial of labor for patients with prior Cesarean. This study measures the change in VBAC rates from 1998 to 2001 and examines possible reasons for this change. STUDY DESIGN: We examined birth certificate and hospital data in the State of Maine from 1998 to 2001. Hospital-specific rates for primary Cesareans, total Cesareans, repeat Cesareans and vaginal deliveries after previous Cesarean were obtained. Additionally, we surveyed current obstetric-care providers in Maine regarding reasons for change in VBAC rates at their institutions. RESULTS: VBAC rates declined by over 50% from 30.1 to 13.1%. The total Cesarean rate climbed from 19.4 to 24.0%. The most commonly reported reason for decrease in VBAC varied depending on whether a practitioner's hospital met ACOG guidelines. CONCLUSION: A marked decline in VBAC occurred after the change in ACOG vaginal birth after Cesarean policy. Multiple factors have contributed to this decline, including patients refusing VBAC after counseling and inability of institutions to meet ACOG guidelines.     

‘Stress,anger, fear and injustice’: An international qualitative survey of women's experiences planning a vaginal breech birth

Objectivethe outcomes of the Term Breech Trial had a profound impact on women's options for breech birth, with caesarean section now seen as the default method for managing breech birth by many clinicians. Despite this, the demand for planned vaginal breech birth from women does exist. This study aimed to examine the experiences of women who sought a vaginal breech birth to increase understanding as to how to care for women seeking this birth option.Designan electronic survey was distributed to women online via social media. The survey consisted of qualitative and quantitative questions, with the qualitative data being the focus of this paper. Open ended questions sought information on the ways in which woman sourced a clinician skilled in vaginal breech birth and the level of support and quality of information provided from clinicians regarding vaginal breech birth. Thematic analysis was used to analyse and code the qualitative data into major themes.Findingsin total, 204 women from over seven countries responded to the survey. Written responses to the open ended questions were categorised into seven themes: Seeking the chance to try for a VBB; Encountering coercion and fear; Putting the birth before the baby?; Dealing with emotional wounds; Searching for information and support; Traveling across boundaries; Overcoming obstacles in the system.Key conclusionsfor women seeking vaginal breech birth, limited system and clinical support can impede access to balanced information and options for care. Recognition of existing evidence on the safety of vaginal breech birth, as well as the presence of clinical guidelines that support it, may assist in promoting vaginal breech birth as a legitimate option that should be available to women.     

Vaginal Breech Birth: Can We Move Beyond the Term Breech Trial?

Since the publication of the Term Breech Trial in 2000, planned cesarean has become the preferred mode of birth for women whose fetus is in a breech presentation. Over the past 20 years, however, subsequent evidence has not shown conclusively that cesarean birth is safer than vaginal birth for a fetus in a breech presentation when certain criteria are met. Many obstetric organizations support the option of planned vaginal birth for women with a breech presentation under strict prelabor selection criteria and intrapartum management guidelines. The growing trend toward cesarean unfortunately has left midwives and other intrapartum care providers in training with dwindling opportunities to competently master skills for vaginal breech birth. Although simulation training offers opportunities to practice infrequently encountered skills such as vaginal breech birth, it is unknown if this alternative will provide sufficient experience for future generations of clinicians. As a result, women with a breech presentation at term who desire a trial of labor often have limited choices. This article reviews the controversies surrounding the ideal mode of birth created by the Term Breech Trial. Criteria for vaginal breech birth are summarized and the role of simulation explored. Implications for midwifery practice when a breech presentation is diagnosed are also included.     

Term breech singletons and caesarean section: A population study, Australia 1991–2005

Objective: To describe the method of birth of term breech singletons in Australia.
Design, setting and participants:  A retrospective population-based study of women who gave birth to term breech singletons in Australia between 1 January 1991 and 31 December 2005 using data from the National Perinatal Data Collection.
Main outcome measures:  Caesarean section, vaginal breech birth.
Results:  Method of birth changed for term breech singletons from 1991 (vaginal breech birth 23.1% versus caesarean (no labour 55.6%, labour 21.2%)) to 2005 (vaginal breech birth 3.7% versus caesarean (no labour 76.6%, labour 19.7%)). Overall, the population attributable risk percentage of term breech singletons for all caesarean sections declined from 10.2% in 1991 to 6.9% in 2005.
Conclusion:  Planned caesarean section is the standard method of birth for term breech singletons in Australia. Active measures including external cephalic version should be supported to reduce the rate of caesarean section where clinically indicated. Retention of a skilled clinical workforce is essential in the provision of the latter and to assist the minority of women having vaginal breech births. Breech presentation is not a major factor in the overall rise in caesarean section experienced by Australia since 1996.     

Singleton Breech at Term: Two Continents Two Approaches

Breech presentation is a complication in 3% to 4% of singleton pregnancies at term. On the strength of a large study published in the early 2000s, the American College of Obstetricians and Gynecologists (ACOG) recommended Caesarean section be routinely performed in such cases. However, French gynaecologists continue to perform vaginal breech deliveries. Through various observational studies, they have shown that their management approach, although different from the one used in North America, is safe. In 2006, the ACOG declared that vaginal delivery of a breech presentation may be acceptable under specific circumstances. In this analysis, we compare North American and French practices and present a protocol of care for the management of term breech presentation based on French recommendations.     

Use of External Cephalic Version for Breech Pregnancy and Mode of Delivery for Breech and Twin Pregnancy: A Survey of Canadian Practitioners

Objectives: (1) To understand how external cephalic version (ECV) is used in the management of breech pregnancies; (2) to determine if Canadian practitioners have changed their recommendations regarding the mode of breech delivery since becoming aware of the findings of the Term Breech Trial; and (3) to establish a baseline of how twins are being delivered in Canada.Methods: In March 2001, a survey was mailed to 920 obstetrician/gynaecologists, 409 family physicians, and 62 midwives from the membership list of the Society of Obstetricians and Gynaecologists of Canada.Results: The response rate was 52% (476/920) for obstetrician/gynaecologists, 22% (90/409) for family physicians, and 53% (32/62) for midwives. Eighty-nine percent of practitioners routinely offered women ECV. The median self-estimated ECV success rate for nulliparous women was 30%, and for multiparous women, it was 58%. Forty-seven percent of practitioners used tocolytics 9% used analgesics, and 14% recommended repeat ECV when initial attempts failed. Eighty-four percent of practitioners recommended vaginal breech birth before learning the results of the Term Breech Trial, and 14% afterwards. When both twins present as vertex, most respondents planned vaginal delivery (100% for term, 95% for preterm > 32 weeks, and 73% for preterm ≤ 32 weeks). Vaginal birth was recommended for Twin A vertex, Twin B breech at term by 92% of practitioners for frank, 92% for complete, and 88% for footling breech at Preterm > 32 weeks by 84% of practitioners for frank, 81% for complete, and 78% for footling breech; and at preterm ≤ 32 weeks by 43% of practitioners for frank, 42% for complete, and 39% for footling breech pregnancies. When Twin A was non-footling breech and Twin B vertex 7%, 5% and 2% of practitioners recommended vaginal birth for term, preterm > 32 weeks, and preterm ≤ 32 weeks pregnancies, respectively. Sixty-four percent of respondents on twin births were interested in a randomized controlled trial to compare planned Caesarean section with planned vaginal birth for twin pregnancies.Conclusion: Although the use of ECV is high in Canada, the success rate is low. Increasing the use of tocolytics, considering epidural analgesic, and repeating the procedure when the initial attempt fails may increase success and decrease Caesarean section rates. The survey results reflect a dramatic shift toward recommending Caesarean section for management of term breech pregnancies. Vaginal birth is the method of delivery of choice for most twin pregnancies of 32 weeks’ gestation, especially for vertex/vertex presentations.     

Breech birth: an unusual normal

Over the last decade, there has been a loss in confidence and eroded skills due to the near universal policy of advising caesarean section in the wake of the Term Breech trial (Hannah et al 2000). Breech birth has been increasingly viewed as a complication, and management of the breech presenting baby at term has shifted firmly into the realm of obstetric practice in most parts of the UK. Small pockets of exception remain, among NHS and independent midwives who have maintained their skills with breech birth and are sought out by women denied the choice of a vaginal birth elsewhere. With continued focus on consumer choice, women led care and increasing normality, we urgently need to address the issue of how the NHS can safely provide the option of normal breech birth before these skills are permanently lost. This article suggests ways midwives may play a role within the NHS in ensuring women have a choice to birth their breech babies normally, in the safest possible way.     

Systematic Review of Nulliparous Women’s Views of Planned Cesarean Birth: The Missing Component in the Debate about a Term Cephalic Trial

Abstract: Background: The suggestion that planned cesarean birth is gaining acceptance among women has led some physicians to advocate the need for a trial of primary planned cesarean section versus planned vaginal birth in healthy women with singleton cephalic pregnancies at term. This paper reviews published studies of nulliparous women’s views of mode of birth collected in the antenatal period, examining why women may express a preference for cesarean birth and exploring implications for the debate about the need for a trial. Methods: A systematic literature review was undertaken of Cochrane, CINAHL, EMBASE, MEDLINE, and PsycINFO using the MeSH heading “cesarean section” and four free text spellings of “cesarean,” or “birth” or “delivery,” near truncated synonyms of 17 words meaning expressed preference. Studies of nulliparous women with a medical indication for cesarean birth, studies where a woman’s preference for mode of birth was reported in the postpartum period, surveys of midwives or obstetricians, and opinion and non‐English language papers were all excluded. Results: Nine papers were included in the review, which reported rates of women expressing a preference for cesarean birth that ranged from 0 to 100 percent at recruitment. However, the papers raised specific methodological, conceptual, and cultural issues that may have influenced women’s preferences for mode of birth in the populations studied. These issues included the timing and frequency of data collection, complexity of factors determining individual women’s decision making, and influence of societal norms. Conclusions: Little evidence is available that an increasing cultural acceptance of cesarean delivery will bring about support for a trial among pregnant nulliparous women. Further qualitative research investigating the influence of both obstetric and psychosocial factors on women’s views of vaginal and cesarean birth is required. (BIRTH 33:3 September 2006)     

Outcomes of Free‐Standing,Midwife‐Led Birth Centers: A Structured Review

Abstract: Background : Over the last two decades, childbirth worldwide has been increasingly concentrated in large centralized hospitals, with a parallel trend toward more birth interventions. At the same time in several countries, interest in midwife‐led care and free‐standing birth centers has steadily increased. The objective of this review is to establish the current evidence base for free‐standing, midwife‐led birth centers. Methods : A structured review, based on Cochrane guidelines, was conducted that included nonrandomized studies. The comparative outcomes measured were rates of normal vaginal birth; cesarean section; intact perineum; episiotomy; transfers; and babies remaining with their mothers. Results : Of the 5 controlled studies that met the review criteria, all except one was a single site study. Since no study was randomized, meta‐analysis was not performed. The included studies all raised quality concerns, and significant heterogeneity was observed among them. For the outcomes measured, every study reported a benefit for women intending to give birth in the free‐standing, midwife‐led unit. Conclusions : The benefits shown for women recruited into the included studies who intended to give birth in a free‐standing, midwife‐led unit suggest a question about the efficacy of consultant unit care for low‐risk women. However, the findings cannot be generalized beyond the individual studies. Good quality controlled studies are needed to investigate these issues in the future.     

Vaginal delivery of breech presentation : No. 226, June 2009

Objectives

To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth.

Options

Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term.

Outcomes

Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality.

Evidence

Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008.

Values

The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care.

Validation

This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery.

Sponsors

The Society of Obstetricians and Gynaecologists of Canada.     

Trends in the management of the breech presentation at term; experience in a District General hospital over a 10-year period

BACKGROUND: The recent evidence from a randomised controlled study on the management of breech delivery has settled the argument, however, this has not been to everybody's satisfaction. Elective delivery of all full term breech babies has implications. However, the trend seems to have been set long before the recent evidence, which is bound to accelerate the changes. MATERIALS AND METHODS: This is a retrospective observational study in a district general hospital. All planned term singleton (> or = 37 weeks gestation) breech deliveries between 1988 and 1997 were reviewed to assess changes in the management of the term breech delivery over a 10-year period. The main outcome measure was the trend of the intended mode of delivery correlated with the time period of the study and its effect on the neonatal and maternal outcome. RESULTS: There was a significant almost linear increase in the planned elective caesarean birth rate over the study period (OR = 1.25, 95% CI = 1.18-1.32). This was associated with a significant decline in neonatal intubation but no other effect on maternal or neonatal morbidity. There was no effect on perinatal mortality. CONCLUSIONS: Caesarean section has gradually become the preferred mode of delivery for the term breech presentation, despite prior lack of clinical evidence This change in trend may be influenced by maternal wishes. Reduced experience in the conduct of vaginal breech deliveries will have important implications for future obstetric specialists. A trial of vaginal delivery should be allowed in suitably selected cases before obstetricians lose the skills and confidence in performing an assisted vaginal breech delivery.     

Outcomes associated with cesarean section versus vaginal breech delivery at a university hospital.

OBJECTIVE: To determine whether vaginal breech delivery is associated with increased morbidity in term breech singletons using strict selection criteria. This study encompasses our previous studies (in 1987 and 1995) and extends our experience to 21 years. STUDY DESIGN: Retrospective cohort study from 1980 to 2001 including term, non-anomalous singleton breech deliveries selected by strict criteria. Univariable and multivariable analyses were performed for neonatal and maternal outcomes. RESULTS: Five hundred and eleven women underwent cesarean section and 214 a trial of labor. We found greater overall maternal morbidity in the cesarean section group (odds ratio (OR) 1.89, 95% confidence interval (CI)=1.34-2.65). In the vaginal delivery group, neonates were more likely to have had >1 day of mechanical ventilation (OR 10.0, 95% CI=1.56-63.9). No maternal deaths occurred and no neonatal deaths or seizures occurred. CONCLUSION: Given our findings, offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option.     

Vaginal breech delivery at term and neonatal morbidity and mortality – a population-based cohort study in Sweden

Introduction: The routine to deliver almost all term breech cases by elective cesarean section (CS) has continued to be debated due to the risk of maternal and neonatal complications. The aims of the study were (1) to investigate if mode of delivery impacts on the risk of morbidity and mortality among term infants in breech presentation and (2) to compare the rates of severe neonatal complications and mortality in relation to presentation and mode of delivery.

Methods: This population-based cohort study used data from the Swedish Medical Birth Register. All women (and their newborn infants) with singleton pregnancies who gave birth at term to an infant in breech (n?=?27,357) or cephalic presentation (n?=?837,494) between 2001 and 2012 were included. Births with vacuum extraction and induced labors were excluded, as well as antepartum stillbirths, births with infants diagnosed with congenital malformations and multiple births.

Results: On one hand, the rates of neonatal complications and mortality were higher among infants born in vaginal breech compared to the vaginal cephalic group. On the other hand, after CS, the rates of all neonatal complications under study and neonatal mortality were lower among infants in breech presentation than in those in cephalic presentation. After adjustment for confounders, infants delivered in vaginal breech had 23.8 times higher odds AOR (ratio) for brachial plexus injury, 13.3 times higher odds ratio for Apgar score <7 at 5?min, 6.7 times higher odds of intracranial hemorrhage (ICH), or convulsions and 7.6 higher odds ratio for perinatal mortality than those delivered by elective CS.

Conclusions: Despite a probable selection of women who before-hand were considered at low risk and, therefore, could be recommended vaginal breech delivery, infants delivered in vaginal breech faced substantially increased risks of severe neonatal complications compared with infants in breech presentations delivered by elective CS.

• Key message

• Vaginal breech delivery is associated with increased risk for severe neonatal complications.

     

Primigravid Women's Views of Being Approached to Participate in a Hypothetical Term Cephalic Trial of Planned Vaginal Birth versus Planned Cesarean Birth

Background: Several papers have called for a trial of planned cesarean section versus planned vaginal birth for low‐risk women—a recommendation that is fiercely debated. Although proponents of a trial have voiced their support, evidence suggests that in the United Kingdom few midwives and obstetricians believe such a trial to be feasible, and no studies reporting women's views on the prospect of such a trial have been published. The purpose of this study is to explore women's views of participation in a trial of planned cesarean birth versus planned vaginal birth. Methods: A qualitative study was conducted using in‐depth interviews in a large maternity hospital in the United Kingdom. Sixty‐four women were interviewed 12 months after giving birth. Women were asked “How do you think you would have felt if you had been approached to take part in such a trial during your first pregnancy?” Data were analyzed thematically. Results: Only 3 of the 64 women stated that they would have participated in a trial of planned vaginal birth versus planned cesarean section, had they been asked. However, five other women said that they would have consented to participate if they had been asked during pregnancy, but with hindsight, would have regretted that decision. The remainder of women would not have participated, unless a preference arm was offered. Three main themes were identified: “feeling cheated,”“let nature take its course, ” and “just another trauma that you don't need.” Conclusions: Few women supported a trial and most suggested that it was intuitively wrong. Given the strong views voiced by women, it is unlikely that a trial of planned vaginal delivery versus planned cesarean delivery would be feasible.     

Evolving Evidence Since the Term Breech Trial: Canadian Response,European Dissent,and Potential Solutions

ObjectivesWe wished to gain insight into Canadian hospital policy changes between 2000 and 2007 in response to (1) the initial results of the Term Breech Trial suggesting delivery by Caesarean section was preferable for term breech presentation, and (2) the trial’s two-year follow-up and other research and commentary suggesting that risks associated with vaginal breech delivery and delivery by Caesarean section were similar. We also wished to determine the availability of vaginal breech delivery and the feasibility of establishing breech clinics and on-call squads, and whether these could include midwives.MethodsIn 2006, we sent surveys to the 30 largest maternity centres in Canada asking about their changes in practice in response to results of the initial Term Breech Trial and the subsequent two-year follow-up and the possibility of establishing breech clinics and on-call delivery squads and whether they could include midwives.ResultsOf the 30 surveys sent, responses were received from 20 maternity centres in six provinces. Hospitals were almost five times more likely to adopt a policy of requiring Caesarean section for breech delivery when current evidence suggested that it decreased risk for the neonate than they were to reintroduce the option of vaginal breech delivery when it did not. A breech clinic was considered possible, feasible, and desirable by only one centre, and forming a breech squad was similarly regarded by only two hospitals; 70% of respondents, however, did not entirely dismiss either possibility.ConclusionsThe weight of epidemiologic evidence does not support the practice developed in Canadian hospitals since the Term Breech Trial that recommends delivery by Caesarean section for all breech presentations. Obstetric and midwifery bodies will require creative strategies to make clinical practice consistent with current national and international evidence.     

Mode of term singleton breech delivery

Recently, researchers conducted a large, international multicenter randomized clinical trial comparing a policy of planned cesarean birth with planned vaginal birth. Given the results of this exceptionally large aand well-controlled clinical trial, the American College of Obstetricians and Gynecologists Committee on Obstetric Practice recommends that obstetricians continue their efforts to reduce breech presentations in singleton gestations through the application of external cephalic version whenever possible. As a result of the findings of the study, planned vaginal delivery of a term singleton breech may no longer be appropriate. In those instances in which breech vaginal deliveries are pursued, great caution should be exercised. Patients with persistent breech presentation at term in a singleton gestation should undergo a planned cesarean delivery. A planned cesarean delivery does not apply to patients presenting in advanced labor with a fetus in the breech presentation in whom delivery is likely to be imminent or to patients whose second twin is in a nonvertex presentation.     

The term breech presentation: Neonatal results and obstetric practices in France

OBJECTIVE: Compare neonatal complications according to the planned mode of delivery and according to whether the women gave birth at a maternity unit that applied "consensus" guidelines. STUDY DESIGN: The study used the database of the AUDIPOG Sentinel Network (n=71,919 pregnancies between 1994 and 2000). The principal outcome was a composite variable that included neonatal morbidity and mortality. A survey of obstetric practices was sent to 175 maternity units belonging to the network. Consensus guidelines were defined from the survey responses and taken into account in the database analysis. RESULTS: Neonatal complications did not differ between the group of women with term babies in breech presentation for whom vaginal delivery was planned and those for whom an elective caesarean was planned (adjusted OR=1.33; 95% CI: 0.63-2.80). The survey allowed us to define a set of six criteria for deciding on mode of delivery; it established a consensus, followed by 42% of the maternity units in the study. The rate of neonatal complications among the women with planned vaginal delivery was lower for those giving birth in units that applied the consensus guidelines than among those in the other units: adjusted OR=0.27 (95% CI: 0.09-0.85). CONCLUSION: The risk of neonatal morbidity according to planned mode of delivery for term breech babies was lower for those giving birth in units that applied the consensus guidelines than among those in the other units.     

Safety of term vaginal breech delivery

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.     

Postpartum Early Hospital Discharge and Follow-up Practices in Canada and the United States

Background: Although official guidelines and recent legislation have addressed early postpartum hospital discharge and follow-up, little is known about the practices of obstetricians in Canada and the United States on this issue. Methods: Questionnaires were mailed to two separate random samples of 2000 Fellows of the American College of Obstetricians and Gynecologists (ACOG) in the United States and all Canadian Fellows. Practices and perceptions were compared with those recommended in the literature, recent legislation, and guidelines of ACOG and American Academy of Pediatrics (AAP). Results: In contrast to concerns expressed in the medical literature and official AAP/ACOG guidelines, many physicians considered potential psychosocial and demographic risk factors relatively unimportant in making early discharge decisions, preferring to emphasize aspects of the patient's medical condition, hospital course, and social support. Although the official guidelines encourage follow-up for all patients discharged early, additional visits are routinely advised by only 39 percent of obstetricians after vaginal delivery and by 68 percent after cesarean section. After vaginal delivery 39 percent of obstetricians used telephone follow-up and 37 percent after cesarean delivery. Moreover, although the official guidelines recommend follow-up within 48 hours of discharge, only one-half of the obstetricians surveyed advised follow-up at this time. In contrast to the guidelines, most obstetricians defined early discharge as that occuring within 24 hours after vaginal delivery and 72 hours after cesarean delivery; most defined optimal lengths of stay within the 48-hour (after vaginal delivery) and 96-hour (after cesarean delivery) periods considered short by the guidelines. Conclusions: Current postpartum early discharge and follow-up practices emphasize the physical health of the mother and place little emphasis on social risk. They appear to be influenced by perceptions of the appropriateness of the length of stay and are not in agreement with professional guidelines. (BIRTH 25:3 September 1998)