The news that obstetricians at ACOG have published less restrictive guidelines for VBAC is good news for women that desperately want to avoid repeat cesarean surgery and who feel that their decision to plan a trial of labor is neither respected - or in many cases, and particularly in American hospitals, allowed.
But now for the not so good news...
First of all, I suggest that you read ACOG's press release for yourself, and then come back to read my thoughts on some of its contents, below.
ACOG PR: "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..."
*Just a small observation I've made while perusing much of the media and blog reporting of this story - the number of headlines and bylines that have dropped the crucial word "most" from the sentence above. This is a very dangerous interpretation of what ACOG has said.
ACOG PR: "The cesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, it became viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits."
*It is important to remember that many women prefer to have a repeat cesarean, and are more than happy not to plan a VBAC, and their birth plan decision should not be refused or disrespected in this attempt to "swing the pendulum back".
ACOG PR: "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."
*I find it disappointing and indeed disconcerting that 'more reasonable rates' has even been mentioned in the context of patient autonomy here. What is a 'more reasonable' rate of VBAC? And perhaps more importantly, what is considered a reasonable rate of TOLAC? A 25-year-old argument over the optimum percentage rate of cesarean deliveries came to a head last year when the WHO admitted that there is no evidence for one, so who's got the answer to the 'right number' of VBACs and TOLACs?
I think that if, instead of target rates, we let patient autonomy (where patient autonomy is requested - remember, there are many women who are more than happy to be guided and advised by their doctor or midwife, with no personal delivery preference either way) take a greater role in maternity care... if we provide women with the risks and benefits and let them decide which birth plan they prefer... if assessment of birth outcomes includes maternal satisfaction... then the rates will fall where they will, and more women and babies will be happier and healthier for it.
ACOG PR: "In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriate candidates who attempt VBAC will be successful."
*This is important to understand. Approximately 60-80% of appropriate candidates will have a successful VBAC. This means that approximately 20-40% will be unsuccessful - a risk many women are not comfortable with.
And when ACOG's statement is misinterpreted by stating that VBAC might be safe for all women, it completely ignores the fact that the cited 60-80% success rate is ONLY for women firstly established as appropriate candidates. The success rate if all women with previous cesareans were included is much lower.
ACOG PR: "The risk of uterine rupture during a TOLAC is low - between 0.5% and 0.9% - but if it occurs, it is an emergency situation. A uterine rupture can cause serious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.
"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."
Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added.
*In summary, it appears that the criteria for a TOLAC/VBAC birth plan has changed from requiring the availability of "immediate" emergency care for the laboring women, to that which is "quickly gathered".
The change of wording here is worthy of a blog post all of its own, but I mention it here because what happens in the inevitable cases of uterine rupture emergencies is crucial, and I think that while ACOG has done well to address the fundamental issues of insurance and litigation, questions remain.
How do we remove doctors' fears of being sued when a TOLAC fails? Do insurers now agree with ACOG that 'quickly gathered' emergency care is sufficient duty of care? Will women be asked to sign a waiver stating that they are fully aware of the risks of uterine rupture and its possible consequences? There are no easy answers to all this, and again, while helping women gain access to wanted VBACs is commendable, ACOG's statement might have provided more in the way of broadening discussion of these, and other, continuing challenges.
ACOG PR: The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center."
*As mentioned above, I applaud ACOG's efforts to help women who feel they are being given no choice when it comes to VBAC versus a repeat cesarean, but I just wish that this was the sole focus of its statement, with nothing said about the shared desire to swing the pendulum back on percentage rates. Has it occurred to anyone that when women are informed about the risks and benefits of VBAC, the number of women that actually choose VBAC may not swing the pendulum back as far as some may imagine? I guess only time will tell.