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ACOG Says Yes to VBACs

Amie Newman

Good news from the American College of Obstetricians and Gynecologists (ACOG) yesterday. The group issued updated guidelines on vaginal birth after cesareans (VBACs), hopefully paving the way for more women to choose vaginal birth, after a previous c-section.

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.

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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  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.