Vaginal Birth After Cesarean

Recorded on May 26th, 2021 at 7:00PM EDT


FREE for ObGFirst® Members!

Includes CME


Faculty: Sara Petruska, MD, University of Louisville

Moderators: Rebecca Dunsmoor-Su, MD

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Learning Objectives 

  1. Assess factors that impact risks and benefits of a trial of labor after cesarean
  2. Describe the role of maternal autonomy in the decision for cesarean
  3. Assess the patient’s chance for a successful trial of labor
  4. Identify factors that patients may weigh when deciding the value successful VBAC holds for them

Disclosures

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:

Faculty: Sara Petruska, MD has nothing to disclose.

Rebecca Dunsmoor-Su, MD receives a salary from Gennev, and consulting fees from ObG Connect. Dr. Dunsmoor-Su has a financial ownership Interest in Gennev and ObBest Practice LLC

The PIM planners and others have nothing to disclose.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education 

Postgraduate Institute for Medicine designates this enduring material for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Can Evidence-Based Interventions Reduce C-section Complications?

BACKGROUND AND PURPOSE:

  • Temming et. al. (AJOG, 2017) sought to estimate the impact of evidence-based measures to prevent cesarean section wound complications including
    • Appropriate timing of prophylactic antibiotics within 60 minutes of cesarean delivery and before skin incision
      • 2 g of cefazolin preoperatively for maternal weight <120 kg and 3 g for maternal weight ≥120 kg
      • Penicillin or cephalosporin allergy: 2 mg/kg gentamicin and 900 mg clindamycin
    • Chlorhexidine-alcohol for skin antisepsis with 3 minutes of drying time before incision
    • Closure of subcutaneous layer if ≥ 2 cm of depth
    • Subcuticular skin closure with suture

METHODS:

  • Secondary analysis of data from a randomized controlled trial (RCT) of 1082 chlorhexidine-alcohol vs iodine-alcohol for skin antisepsis at cesarean delivery between 2011-2015
  • Subjects were characterized as one of the following:
    • Received 4 evidence-based measures (listed above), or
    • Did not receive the measures
  • Primary Outcome was a composite of wound complications within 30 days of delivery
    • Surgical site infection
    • Cellulitis
    • Seroma
    • Hematoma
    • Wound separation
  • Secondary outcomes
    • Individual components of the composite outcome

RESULTS:

  • When comparing patients who received all the evidence-based measures compared with those who did not
    • The risk of any wound complications was significantly lower (20.3% vs 28.1%; adjusted relative risk 0.75 (95% CI 0.58-0.95)
  • The impact appeared to be driven by surgical site infection reduction (3.7% vs 9.3%; adjusted relative risk 0.43 (95% CI 0.24-0.76)
  • Of patients who received evidence-based measures, unscheduled cesarean delivery was the only risk factor for wound complications
  • Other risk factors, which include obesity, smoking, diabetes mellitus, chorioamnionitis, surgical experience, and skin incision type, were not significantly different between patients who received all measures and those that did not

CONCLUSION:

  • Implementation of evidence-based measures significantly reduces wound complications
  • However, the residual risk remains high, suggesting the need for additional interventions, especially to reduce unscheduled cesarean deliveries

Learn More – Primary Sources:

Impact of evidence-based interventions on wound complications after cesarean delivery