Selecting Patients for Vaginal Birth After Cesarean Section: The Maryland Hospital's Experience

Abstract

The purpose of this study was to determine if patient selection for cesarean section or vaginal birth after cesarean section had changed in Maryland between 1987 and 1989 based on changes in severity of illness scores in a group of parous women. Data from a total of 20 hospitals and 91,155 patients were analyzed using a computerized disease staging algorithm to compare cesarean section rate trends with severity of illness score trends. A subset of eight hospitals was further analyzed to identify variation patterns in patient severity of illness scores over time. Trends of cesarean section rates did not correlate with severity of illness scores (i.e., the decrease of cesarean section rates was not accompanied by a continuous decrease in the severity of illness scores of VBAC patients), although a decrease was observed in the average severity of illness scores for the cesarean section group in six of the eight hospitals. The findings suggest that factors other than clinical patient profiles may influence clinical decision making for VBAC vs cesarean section delivery. It is not clear whether clinical decisions regarding VBAC minimize maternal and neonatal mortality and morbidity while minimizing cesarean section delivery. At present, systematic selection of patients for VBAC does not appear to be occurring.