Good news from the American College of Obstetricians and Gynecologists (ACOG), on VBACs (Vaginal Birth After Cesearean). 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 uterinte rupture, according to ACOG themselves, is extremely low, occurring in one-half of one percent of all cases (though serious, requiring emergency surgery). 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.
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.”
ACOG acknowledged that these 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."
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. 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.