Health Knowledge On The Vagina Birth After Cesarean Guidelines

- The dictum "once a cesarean, always a cesarean " was well followed in the United
States for the greater part of 20th century. By 1980, 98% of women who had previous
cesarean delivery underwent a routine repeat cesarean for any subsequent
pregnancy. Decades later. this old maxim still holds trace for same and contributes
to the overall rise in cesarean delivery rates seen today ( canning ham et al 2010 )

- In 1980, the National Institutes of Health (NIH) publicly called the maxim into
question and suggested that this practice may not always be necessary [ NIH
Consensus Statement 1980 ]

- The NIH examined the need of routine repeat cesarean delivery and defined
situations in which vaginal birth after cesarean ( VBAC ) could considered. And from
studies done after 1960, it was confined that women who had previous undergone
cesarean delivery could safely attempt a trial of labour ( TOLAC ) to have a vagina
delivery in subsequent pregnancies ( Guise et al 2010 ).

Problem Statement

- In United States and other developed countries, the vaginal birth after cesarean
(VBAC) rate has been steadily declining for more than a decade. Only 8.2% of us
women with a previous cesarean delivery attempted a vaginal birth in 2007,
compared with 35.5% in 1997 , despite evidence that 60% to 80% of VBAC are
successful.

- A similar tread is apparent in Australia where VBAC rates declined from 31% in
1998 to 19% in 2006.

- Concerns over the rising cesarean rate in the canted states prompted the National
Institutes of Health (NIH) to convince the fist Consensus Development Conference
Panel on Cesarean childbirth in 1981. The panel recommended that a trial of labour
was a safe and reasonable alternative to an elective repeat cesarean delivery for
carefully selected women.

- The American College of Obstetricians and gynaecologists (ACOG) also published

a series of VBAC guidelines that were successively less restrictive and suggested
that a trial of labour be encouraged in women who were at low risk for complications.

- The ACOG guidelines also specified that " VBAC should be attempted in
institutions equipped to respond o emergencies with physicians immediately
available to provide emergency care ", this recommendation however was based
primarily on consensus and expert opinion rather than on research evidence.
Objective of the study

- General objective the aim of this explanatory quantitative study was to explore the
knowledge associated with the ACOG ( American College Of Obstetricians And
Gynaecologists ) VBAC guidelines as well as the strategies that obstetricians and
midwives use to minimize their legal risks when offering a trial of labour after
cesarean.

- To determined the social demographic.

Significance of the study

Offer understanding the ACOG VBAC guidelines to the healthcare providers.

- ACOG adopted clinical management practice guidelines in 2010 to provide realistic

guidelines for managing and counselling women who are candidates for VBAC (
ACOG 2010 ).Grounded in scientific evidence, recommendations were made. Based
on the highest level of evidence found, the clinical guidelines states, " that most
women with one previous cesarean delivery withal low - transverse incision are
candidates for and should be counselled about VBAC and offered TOLAC
(ACOG-2010). This guideline is based upon the most consistent scientific evidence
and yields the highest chance for VBAC success.

- Through the literature review, date was found that is consistent with and in support
of the ACOG clinical guidelines. A majority of the research studies concluded that a
successful VBAC most likely occurs under the following conditions.

 Prior cesarean incision was low transverse

 An adequate pelvis and normal fatal side
 No other uterine scars, anomalies or previous rupture
 Previous vaginal delivery
 Informed consent
 Spontaneous labor
 Ability to perform emergency cesarean delivery ( ACOG 2010, Baskett and
Keiser 2002, Morrrero 2012, NIH 2010, Scott 2011 )

- Although VBAC has a 60-80% success hope, the following condition should alert
caution and may also be potential contraindication to a VBAC :

 Prior classical of T-shaped incision or previous fundar surgery.

 Prior uterine rupture.
 Recurrent indication for initial cesarean delivery.
 Macosomia or large for gestational age.
 Cepholoervic disproporrtion
 Patient refusal
 Marpresentation
  Have had more than two cesarean
 Vaginal deivery is contraindicated due to an obstetric or medical complication
 Inability to perform emergency cesarean delivery ( ACOG 2010, Baskett and
Keiser 2002, Morrero 2012, NIH 2010, Scott 2011 )

- Healthcare professionals should be aware of the factors that contribute to a

successful VBAC, as well as the contraindications so that they can offer safe, high-
quality care.

Limitations of the study

Small sampre

- Collecting data is time consuming and expensive, even for relatively small amounts
of data. Hence, it is highly unlikely that a complete population will be investigated.
Because of the time and cost elements the amount of data that collect will be limited
and the number of people or organizations in contact will be small in number.
Therefore have to take a sample and usually small sample.

- Sampling theory says a correctly taken sample of an appropriate size will yield
results that can be applied to the population as a whole. There is a lot in this
statement lout the two fundamentar question to ensure genenalization are :

1) How is a sample taken correctly ?

2) How big should the sample be ?

The finding from the studies are limited to study sample.

- A population is the group that wanted to study for investigation and about which will
make a conclusion. Because of cannot always interview or survey an entire
population because it is too large. To pick a small sample , a smaller representative
group, from which you will make generalizations about the population.

Operation Definations

- Fear of liability was a reason for obstetricians and midwives to avoid attending
VBAC. Providers who continues to offer a trial of labor attempted to minimize their
legal risks by being highly selective in choosing potential candidates.

- Midwives were often marginalized due to restrictive hospital policies and by their
consulting physicians even though women with previous cesarean were actively
seeking their care.
Previous Studies

 Healthcare Knowledge

- In 2013, the American Medical Association established a destiration for a

qualified healthcare professional in terms of which providers may report medical
services.

- The UKCC (1986) recognized that is not enough to only have knowledge nurses
also need the ability to appry it in their practice and to be 'Knowledge Deers'.

- It should not be forgotten that it is experience that is needed for the generation
of nursing knowledge and that both type of knowledge are needed to care for
patients effectively ( schultz and meleis 1998 )

 Vaginal Delivery after Caseraen ( VBAC )

- Authoned by London-Rochelle et al this articles reported that the risk of uterine

rupture was higher among those women with a previous whose labor was
induced. As a result VBAC rates steadily declined over the next decade to the
current rate of 8.2% nationwide ( Roberts RG Deutchman M, Ring VJ, Fryer GE,
Miyoshi TJ. Changing Policies on Vaginal Birth )

 Guidelines

- Guidelines present relevant evidence to help physicians weigh the benefits and
risks of a partucular diagnostic or therapeutic procedure. They should be
essential in everyday clinicas decision making ( ESC- European society of
candiology )

Methodology

Research Design

 Quantitative : Descriptive Survey Design

- Quantitative methods emphasize objective measurements and the statistical,

mathematical or numerical analysis of data collected through polls, questionaires
and surveys or by manipulating pre-existing statistical data using computational
techniques. Quantitative research tocuses on gathering numerical data and
generalizing it across groups of people or t explain a particular phenomenon

- Descriptive research seeks to describe the current status of an identified

Variable or phenomenon. The research does not usually begin with an
hypothesis, bat is likely to develop ane after collecting data. Analysis and
synthesis of the data provide the test of the hypothesis. Systematic collection of
information requires careful selection of the units studied and measurement of
each variable in order to demonstrate validity.
Setting of the Study

- Private setting Hospitals in Malaysia

- Consists of Obstetricians. Certified Nurse Midwives, Licensed Midwives,

Registered nurse and Hospital Administrator.

Population

- Populations - 200 beds. 100 nurses and 20 specialist consultant.

- Sample from obstetricians, Midwives and Registered Nurse in Private Setting.

Sampling

- Quantitative study - non random / non probability convenience sampling

technique.

Characteristics

- Not every element of the population has the opportunity for selection in the
sample.

- Not sampling frame

- Populations parameters may be unknown

- Non random selection

- More likely to produce a biased sample

- Restricts generalization

- Historically used in most nursing studies.

Types of non-probability sampling methods

- Convenience-aka chunk, accidental and incidental sampling.