ACOG Says Yes to VBACs


Good news from the American College of Obstetricians and Gynecologists (ACOG), on VBACs (Vaginal Birth After Cesarean). New guidelines were released by the organization yesterday marking a significant change in their recommendations regarding VBACs:

“Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans,” note the guidelines released today by the American College of Obstetricians and Gynecologists.

VBACs have been treated controversially over the years by hospitals and organizations like ACOG, with guidelines and hospital policies designed to bar women from choosing a “trial of labor” for a birth, even after they’ve had one or more prior c-sections. The thought process behind these bans seemed to be most often connected to the fear, by hospital administrators and doctors, of uterine rupture and other complications. Unfortunately, the fear is more perception and suggestion than rooted in fact. The risk of uterine rupture, according to ACOG themselves, is extremely low, occurring in one-half of one percent of all cases (though serious, requiring emergency surgery). It is unquestionably a serious risk to take into consideration when planning for the type of birth one wants to have – but it has been “over-emphasized” by ACOG, according to Lamaze, International, making it more difficult for women to authentically assess the risks vs. complications of a VBAC. Cesarean sections are major surgery though and come with risk and potential complications as well. In addition, the c-section rate in the United States has climbed to dangerous levels, according to the World Health Organization, with one out of every three women birthing via cesarean section.

Just last year Joy Szabo of Page, Arizona was told she’d essentially be forced into have a c-section because her local hospital refused to allow VBACs. She decided, instead, to drive the 350 miles into Phoenix to a hospital that “allowed” her to birth vaginally.

In fact, the hospital in Page, AZ adopted their guidelines banning VBACs because of the way administrators interpreted the original ACOG guidelines suggesting hospitals have a surgeon and anesthesiologist on call during a VBAC. The Page hospital understood these guidelines to mean they needed coverage of both a surgeon and anesthesiologist at the hospital “24/7″ as well as two physicians present at any VBAC. Unfortunately, other hospitals followed suit after ACOG released their original guidelines (which did recommend the “immediate availability” of surgical and anesthesia personnel before allowing a trial of labor for a woman who has had a previous c-section) and VBACs became less and less available over the years.

Birth activists and birth-bloggers who advocated for increased access to VBACs shared their thoughts on the updated guidelines calling them a “breath of fresh air” but also “long overdue.”

ICAN, the International Cesarean Awareness Network, issued its own press release yesterday stating:

“VBAC bans place women in the untenable situation of being forced to undergo unnecessary major surgery if they are unable to find a VBAC supportive alternative. This is a first step in returning to women an appropriate respect for patient autonomy.”

Childbirth Connection is an expert resource on all things related to childbirth, with an unmatched section on their web site on the risks vs. complications on VBACs and C-sections. According to the National Partnership for Women and Families Daily Women’s Health Policy Report, Childbirth Connection’s executive director Maureen Corry took a less rosy view of the changes saying, “Overall, it’s dubious that these guidelines will in fact open up access for women.”

ACOG acknowledged that the original guidelines imposed an undue onus on hospitals:

“Given the onerous medical liability climate for ob-gyns, interpretation of The College’s earlier guidelines led many hospitals to refuse allowing VBACs altogether,” said Dr. Waldman. “Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.”

ACOG likely took into consideration the recent NIH Consensus Development Conference on VBACs in March of this year, from which a statement was developed by a panel of medical experts on the safety of VBACs. The statement included an agreement that VBACs are a “reasonable option” and “safe alternative” for women who have had a prior c-section.

In fact, the chair of the panel of NIH Consensus Conference experts, Dr. F. Gary Cunningham, chair of obstetrics and gynecology at the University of Texas Southwestern Medical Center, noted in reference to the panels’ findings on the safety of VBACs:

“The VBAC rate has gone from 30% to 10% over the last fifteen years… [which] would seem to indicate that planned repeat cesarean delivery is preferable to a trial of labor. But the currently available evidence suggests a very different picture: a trial of labor is worth considering and may be preferable for many women…The use or employment of VBAC is certainly a safe alternative for the majority of women who have had one prior c-section.”

ACOG clearly took note and focused squarely on the rising cesarean section rate in the United States as a key element of their decision to update their guidelines:

“The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” said Richard N. Waldman, MD, president of The College. “These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.”

But The Feminist Breeder, a birth activist and blogger, gave credit where she feels credit is due:

And I don’t think they get the credit here.  I think we do. That’s right – you and me.  So thank you to the the women like Joy Szabo, and Jill from Unnecesarean.  To the women like Desirre Andrews, and Jennifer Block.  To Nicette Jukelevics and Jen from VBACFacts.com.  To the women of ICAN, and the midwives who risk prosecution to attend a home birth after cesarean where the state doesn’t support it.  To all the women who Tweeted, and Facebooked, and Blogged this issue until government health experts couldn’t help but take notice.

We did this.  We made this change happen because we spoke up and insisted on being treated better. But the work is not done yet. Now, we must take this statement to our providers and hospitals and challenge those VBAC “Bans.”  Send the statement to your sisters, coworkers, and friends who may be considering a VBAC.  Write about it, talk about it, and keep spreading the message until VBAC is no longer a four letter word.

These updated guidelines encourage physicians to discuss VBAC “early in the prenatal period” to develop a plan. The group also strongly recommends that hospitals put in place policies that ensure any and all personnel needed for an emergency c-section can be gathered quickly. Unfortunately, it’s this language that still “troubles” Lamaze, International. While the organization was pleased to see updated guidelines, they did take issue with some of the language and what they perceive to be an over-emphasis on the extremely low risk of uterine rupture:

The revised guidelines acknowledge that requiring “immediately available” resources for an emergency cesarean have resulted in hospitals, insurers and the obstetric community issuing formal or informal bans of VBAC, effectively denying women access to care and choice in birth.  While this was not the intention, the “immediately available” language remains in the new guidelines, which may continue to unfairly limit women’s access to VBAC.

Additionally, the guidelines continue to emphasize risks of uterine rupture, a rare, but potentially dangerous complication, for women who choose a VBAC.  Unfortunately, this does not help women contextualize the benefits and risks of VBAC versus elective repeat cesarean delivery (ERCD). 

Women still experience high rates of particular medical interventions which not are always necessary, when birthing at hospitals in this country – from electronic fetal monitoring to labor-inducing drugs – and therefore, even with a trial of labor allowed, it’s important that pregnant women understand how best to reduce their chances for an unnecessary c-section.

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  • relish5k

    This whole thing strikes me as an exercise in futility. They made no substantive changes. The primary reasons VBACs have been so limited is because of that language – “immediately available” and that hasn’t changed.

     

    I just don’t get ACOG. I thought the whole reason that they’re against homebirth is because childbirth is dangerous and anything can happen at any time without any warning, and when it does, you’ll be happy to have the technology immediately available. Except clearly this is not the case. If so many hospitals lack the resources to perform emergency cesarean surgery, then why are we birthing in hospitals again? 

  • amie-newman

    your point and I think, in essence, you’re right. They kept in the language that suggests providers need to be immediately available for an emergency c-section, during a VBAC, but of course if it’s that much “trouble” to have providers (surgeon, anesthesiologist) on staff for an emergency c-section for a woman who wants to go for a trial of labor, why is it any different for any woman who may need an emergency c-section and who needs immediate access to a doctor who can perform the surgery?

    I wonder, in fact, what the stats are for complications for women who chose VBAC as compared to women who have never had a previous c-section and experience a complication during a vaginal birth.

    Of course this seems to be more about not wanting to move towards allowing the notion that birth, for healthy women, can be experienced at home, at a birth center, with a midwife – but rather wanting to keep birth the province of Ob-Gyns or hospital administrators.

  • crowepps

    A new survey finds that babies born via cesarean section had markedly different bacteria on their skin, noses mouths and rectums than babies born vaginally. The research adds to evidence that babies born via C-section may miss out on beneficial bacteria passed on by their mothers.

    Previous research suggests that babies born via C-section are more likely to develop allergies, asthma and other immune system–related troubles than are babies born the traditional way. The new study, to be published online June 22 in the Proceedings of the National Academy of Sciences, offers a detailed look at the early stages of the body’s colonization by microbes, critters that shape the developing immune system, help extract nutrients from food and keep harmful microbes at bay.

    http://www.sciencenews.org/view/generic/id/60461/title/Baby%E2%80%99s_first_bacteria_depend_on_birth_route

  • prochoiceferret

    A new survey finds that babies born via cesarean section had markedly different bacteria on their skin, noses mouths and rectums than babies born vaginally.

     

    It’s an intriguing bit of research on the unknown/unintended consequences of C-section births. But alas, it won’t help with all the men out there who think vaginas are yucky.

  • amie-newman

    crowepps, thank you for posting – I had seen that in passing and found it interesting! It makes sense, of course. There are so many ways in which we may be missing out on providing newborns with the best possible start in life, with possibly negative consequences.

    ProChoiceFerret – that’s hilarious :). But, hey, the study is confirming that science may support that vaginas are just differently “yucky” than abdomens!

  • courtroom-mama

    Here is my take on it (which I hope will serve to cheer you up a little).

    Practice Bulletin 54 was problematic because it was carelessly written. When they used the words “immediately available,” they weren’t thinking like lawyers, and practitioners were subsequently raked over the coals by the plaintiff’s bar as “immediately available” came to mean “able to do an emergency cesarean within 30 minutes from decision to incision” –which I understand is a pretty arbitrary standard anyway.

    Where this recommendation shines is that even though they still say “immediately available,” they emphasize that the intent is not to limit TOLAC, and that women should be able to accept increased levels of risk. Most importantly, the bulletin states that so-called VBAC bans are not justification for forcing women into unwanted repeat cesarean surgery even if they are otherwise not great candidates. 

    From the legal practitioner (and VBAC mama) perspective, I think that this is great. I don’t believe that ACOG practice bulletins were ever actually intended to set the standard of care, but to the extent that they have been interpreted as such, this one is very protective of patient autonomy and informed consent. I think that this should serve to reassure doctors that they will be safe if they carefully counsel their patients about the risks and the patients voluntarily assume the added risk of TOLAC in a smaller facility. This is a reasonable balance compared to some doctors’ insistence that the only way we’ll get our VBACs is by signing away all of our rights…

    (I do think that you have a valid point about the perceived safety of hospitals vs. the actual safety, but that’s a whole other ball of wax!)

  • amie-newman

    thank you for that careful analysis! This is so helpful. I hope you’re right. I fear that hospital administrators will still be overly cautious but I most certainly do see that ACOG has focused in on informed consent and provided some clarity that, with information about the TRUE risks vs complications of VBACs and c-sections, this really should be the woman’s decision, ultimately.

    I do believe that these updated guidelines are clearly a step in the right direction – we’re creating awareness among patients & physicians both, seeing incremental changes on the policy level and hopefully we’ll get to a time, very soon, when women are the ultimate decision-makers about their births, based not in fear and archaic, non evidence-based policies but confidence and solid information!

    By the way, we’re very lucky to have your voice and expertise in this discussion!

  • erinmidwife

    If ACOG wants to commit itself to evidence-based practice it is only logical that they have finally revised (again) their VBAC guidelines to match current evidence. Will this trickle down and effect the way an average OB is practicing, especially in a non-tertiary hospital? I am not convined it will happen any time soon. Our local hospital has not been able to get the anesthesiologists on board to stay in-house, and VBAC have in essence been forbidden since ACOGs previous VBAC guidelines were published. Ultimately I think it is birthing women who need to lead the movement toward women-centered, normal birth in hospitals. History has demonstarted that eft to their own initiative, the docs and administrators will only budge so far from their comfort zone.

  • arekushieru

    Relish, I can assure you that childbirth and pregnancy are indeed the second most life-threatening medical conditions in women, worldwide.   ><;  Sucks, I know, but true.  Still, I do think it seems unlikely that a C-section increases that risk, substantially, at least.

     

    I am not against someone choosing to have a VBAC, but if I were to ever get pregnant or decide by some unknown circumstance to continue a pregnancy, I would still choose a hospital birth and C-section over a home and natural birth and I would definitely choose it, again, no matter how much better health-wise, it would be for me or the fetus, afterwards.   

     

    And that’s where the language in this debate used to start to really niggle at me.  I’m not saying that it’s anyone’s intention, but it really appeared to me that the assumption is that every woman would choose a home and natural birth if they knew that it was less risky.  However, RHReality has alleviated, somewhat if not all, that rhetoric.

  • relish5k

    “Relish, I can assure you that childbirth and pregnancy are indeed the second most life-threatening medical conditions in women, worldwide. “

    Yes, I would appreciate it if you could assure me of that. As in, figures and statistics. Perhaps worldwide pregnancy and childbirth are dangerous for women, because of course under developed countries have tragicaly high rates of maternal mortality. This talk about VBAC is in the US, and there is no way that childbirth and pregnancy are the second most life-threatening medical conditions for women in the US so I really see no reason why you would even bring that up.

    There are many serious complications associated with cesarean section, and while they do outweight the risk of certain labor complications, seeing as 85 percent of women who give birth in the US are healthy, it is reasonable to assume that a 32 percent cesarean rate is causing the costs of cesarean section to outweigh the benefits, and therefore is causing an increase in maternal morbidity amongst childbearing women. If you want to have a planned c-section without medical indication, and if you are thoroughly educated about the benefits and risks associated with that decision, then I say more power to you. But the evidence shows that the high rates of technological medical interventions that are standard components of obstetrics in the US today DO NOT result in optimal outcomes for mothers and babies. It would be great if we could expect to recieve non-invasive care that protects the natural physiological process of birth in hospitals, but unfortunately, due to financial and legal reasons, that’s just not happening.

     

    I would check out these sources to learn more information:

    http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf

    http://www.lamaze.org/OnlineCommunity/LamazeVideoLibrary/LamazeVideoPlayer/TabId/808/VideoId/4/Birth-By-The-Numbers.aspx

  • arekushieru

    No, they aren’t.  But… I thought you wanted something associated most closely with the actual risk of pregnancy.  (Because that is the reason why so many women die from complications, because the actual risk usually makes it too late to save her by the time a doctor recognizes the complications).  And, pushing for VBACS in the US, should naturally lead to pushing for safe VBACS in other, more impoverished, nations (where the problem with complications arising would also still be, unfortunately, inherent), as well… or, at least, I thought.  Sorry if I misinterpreted it….

     

    The  immediate pain of C-Sections would have to outweigh the immediate pain of childbirth.  I thought that that statement was implicit in my previous commentary, because I had already discounted the risks, in and of themselves, for both the fetus and myself.  Once again, I guess I misinterpreted, just believing my own statement said more than it did, this time…? 

     

    I’m sorry, this is an older link and actually says it is the first leading cause of death.  But I am sure there is a more recent link that says it’s the second and I will try and see if I can find it.

     

    http://www.ourbodiesourselves.org/book/companion.asp?id=18&compID=52

     

    And another one for teenaged girls:

     

    http://www.who.int/mediacentre/factsheets/fs334/en/index.html

     

    Besides, I was saying that it was nice to see that RHReality Check actually supports it as informed decision-making rather than always the more wanted option than C-Section as I have seen other places do.