Birth activists including providers have waged a long fight against barriers to VBACs (Vaginal Birth After Cesarean). For too long, they say, women who have had a prior c-sections and would like to attempt a vaginal birth for subsequent pregnancies, have had inadequate access to at least attempting a trial-of-labor. The reasons for the lack of access? Well, it depends upon who you ask.
Ask many hospital adminstrators and ob-gyns and they’d say there’s a risk of uterine rupture (which is true), and that recommended hospital policy, via organizations like the American College of Obstetricians and Gyneocologists (ACOG), has made allowing for women’s access to VBACs extremely challenging. Many hospitals have enacted bans on VBACs. State legislators have even jumped into the fold, attempting to ban VBACs in birth centers and elsewhere.
“…a trial of labor is a reasonable option for many women with a prior cesarean delivery. They [the panel] also urged that current VBAC guidelines be revisited, malpractice concerns be addressed, and additional research undertaken to better understand the medical and non-medical factors that influence decision making for women with previous cesarean deliveries.”
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As well, the panel chair, Dr. F. Gary Cunningham, chair of obstetrics and gynecology at the University of Texas Southwester Medical Center said, of the findings, “The use or employment of VBAC is certainly a safe alternative for the majority of women who have had one prior c-section.”
Then, this summer, ACOG responded. In a widely publicized release, ACOG said they were revising their guidelines on VBACs and noted,
“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.”
The release also stated that the risk of uterine rupture was “low” in a trial-of-labor – between 0.5 percent and 0.9 percent, only slightly higher than for women who undergo repeat cesareans. However, ACOG says, when it does happen, it’s an emergency situation. It’s why their recommendation still includes allowing a trial-of-labor only when appropriate staff (which includes a physician, an anesthesiologist and assistants) can “immediately provide” an emergency cesarean section, if needed.
And while some (including me) thought the revised guidelines were a positive step, many didn’t think the organization’s “new” guidelines would have the impact needed to propel real change and expand access for pregnant women.
Maureen Corry of Childbirth Connection said, “Overall, it’s dubious that these guidelines will in fact open up access for women.” Lamaze International said, according to the National Partnership for Women and Families, that the ‘”immediately available” wording included in the guidelines could still present challenges to women who want to deliver via VBAC.”
The American Academy of Family Physicians also does not support the “immediately available” language; nor does the American College of Nurse-Midwives.
The Coalition for Improving Maternity Services agrees. In a press release issued after the new ACOG guidelines were announced, CIMS praises ACOG for the changes but says it,
“…urges ACOG to reconsider and remove the current selective barrier to women’s access to VBAC stemming from the “immediately available” recommendation.”
CIMS wonders why the call for health care providers to be “immediately available” for an emergency cesarean section should only apply, according to ACOG, to those women who wish to attempt a VBAC? In other words, why is ACOG selectively recommending that appropriate providers are immediately available to undertake a cesarean section in this scenario but not for other potential obstetric emergencies? CIMS notes that, “the risks of potential complications associated with labor after cesarean (less than 1 percent) are comparable to any potential obstetric emergency, such as a cord prolapse that must be dealt with as promptly as possible in any setting.” It does make one wonder since, presumably, hospitals deal with maternity patients of all risk-levels and therefore hospitals would, presumably, be able to deal with the low risk level associated with a possible VBAC as well as they’d be able to deal with other urgent obstetric issues.
The big problem with this, says CIMS, is that the NIH found that this “immediately available” recommendation influenced almost one-third of hospitals and one-half of providers to no longer support VBACs.
On the heels of the NIH consensus conference findings that VBACs are safe and should be more widely accessible for women wishing to undergo a trial-of-labor, CIMS sent a letter to president of ACOG, Dr. Richard Waldman. The letter urged him to reconsider the “immediately available” recommendation because it restrains providers and was originally based on opinion – not evidence-based information. It also requests,
“…ACOG to revise its patient education publications and on-line consumer resources to include comprehensive information on the benefits and risks of cesarean section and VBAC.”
The letter has been signed by 132 organizations and 510 individuals, at this point. Organizations include the American College of Nurse-Midwives, Lamaze International, Our Bodies Ourselves, the American Association of Birth Centers, and the International Childbirth Education Association. ACOG has not responded.
Ultimately, this is not a push for women to undergo VBACs over repeat cesarean sections. This is a challenge to a long-accepted belief that VBACs are so much more dangerous than repeat cesarean sections, for mother and baby, that women’s access should be curtailed or cut off completely. Evidence does not show this to be the case. Maternity care experts no longer agree. If a pregnant woman wishes to explore the potential for a VBAC, and to access the most comprehensive, evidence-based information, she must be able to speak with a provider who not only is willing to share the true risks vs. benefits for her unique situation but who is actually able to ensure she has access to the opportunity.