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About
Birth
Ob-Gyns Issue Less
Restrictive VBAC Guidelines
for
Release: July 21, 2010
Washington, DC -- 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, according to guidelines released
today by The American College of Obstetricians and Gynecologists.
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.
"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."
In keeping with past recommendations, most women with one previous
cesarean delivery with a low-transverse incision are candidates for
and should be counseled about VBAC and offered a TOLAC. In addition,
"The College guidelines now clearly say that women with two previous
low-transverse cesarean incisions, women carrying twins, and women
with an unknown type of uterine scar are considered appropriate
candidates for a TOLAC," said Jeffrey L. Ecker, MD, from
Massachusetts General Hospital in Boston and immediate past vice
chair of the Committee on Practice Bulletins-Obstetrics who co-wrote
the document with William A. Grobman, MD, from Northwestern
University in Chicago.
VBAC Counseling on
Benefits and Risks
"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. A VBAC avoids major abdominal surgery, lowers a woman's risk of
hemorrhage and infection, and shortens postpartum recovery. It may
also help women avoid the possible future risks of having multiple
cesareans such as hysterectomy, bowel and bladder injury,
transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).
Both repeat cesarean and a TOLAC carry risks including maternal
hemorrhage, infection, operative injury, blood clots, hysterectomy,
and death. Most maternal injury that occurs during a TOLAC happens
when a repeat cesarean becomes necessary after the TOLAC fails. A
successful VBAC has fewer complications than an elective repeat
cesarean while a failed TOLAC has more complications than an
elective repeat cesarean.
Uterine Rupture
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.
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.
Practice Bulletin #115, "Vaginal Birth after Previous Cesarean
Delivery," is published in the August 2010 issue of Obstetrics &
Gynecology.
# # #
The American College of Obstetricians and Gynecologists is the
nation's leading group of physicians providing health care for
women. As a private, voluntary, nonprofit membership organization of
approximately 53,000 members, The American College of Obstetricians
and Gynecologists strongly advocates for quality health care for
women, maintains the highest standards of clinical practice and
continuing education of its members, promotes patient education, and
increases awareness among its members and the public of the changing
issues facing women's health care.
The
American College of Obstetricians and Gynecologists (ACOG)
Ob-Gyns Issue Less Restrictive VBAC Guidelines
Medscape
CME Release
"ACOG Issues Less Restrictive Guidelines for Vaginal Birth After
Cesarean Delivery" (You will need to be subscribed to Medscape
to read this brief. Subscription is free and once subscribed
you will receive periodic e-mail notifications of ongoing medical
releases.)
MANA (Midwives
Alliance of North America) responds to ACOG's release:
Press Release about
New ACOG Guidelines:
Vaginal Birth After Cesarean is a Safe Option
Washington, DC - The Midwives Alliance of North America (MANA), a
professional midwifery organization since 1982, commends the
American College of Obstetricians and Gynecologists (ACOG) for their
updated practice guidelines on Vaginal Birth After Cesarean (VBAC)
released July 21, 2010. ACOG's recent guidelines are less
restrictive than previous ones. The new guidelines state that VBAC
is a "safe and appropriate choice" for most women who have had a
prior cesarean delivery, including some women who have had two
previous low-transverse cesarean incisions, women carrying twins,
and women with an unknown type of uterine scar.
There has been a dramatic increase in cesarean delivery in the
United States (from 5% in 1970 to nearly 32% in 2009) and a rapid
decrease of VBACs (from 28% in 1996 followed by a decline to 8% in
2006). Lack of VBAC availability in U.S. hospitals due to
practitioner and institutional restrictions, which diminished
women's choices in childbirth, is often cited as the reason for the
conspicuous decrease in VBACs. In light of the VBAC restrictions
that have become commonplace in most U.S. hospitals, it is
noteworthy that ACOG's new guidelines emphasize a woman's right to
self-determination. The new ACOG guidelines state that even if a
hospital does not offer a trial of labor after cesarean (TOLAC), a
woman cannot be forced to have a cesarean nor can she be denied care
if she refuses a repeat cesarean. In addition, previous ACOG
guidelines on VBAC stated that anesthesia and surgery must be
"immediately available" for an institution to offer VBAC; the new
guidelines have relaxed this restriction.
ACOG has seriously considered recommendations from the National
Institutes of Health (NIH) Consensus Development Meeting on vaginal
birth after cesarean held in Washington DC in March 2010. Based on
the scientific evidence, the NIH expert panel affirmed that risks in
VBACs are low, similar to risks of other laboring women, and repeat
cesareans expose mothers and infants to serious problems both in the
short and long terms. The NIH expert panel concluded that in the
absence of a compelling medical reason, most women should be offered
a trial of labor after cesarean. The NIH expert panel further
recommended that all women be given unbiased educational information
during their pregnancies with which to make decisions regarding VBAC
in partnership with their healthcare providers. Women should also be
offered full informed consent and refusal during their labors.
"While we are pleased that ACOG has issued less restrictive VBAC
guidelines and affirmed a woman's autonomy in her childbirth
experience, it is still up to women to take charge of their lives,
educate themselves about childbirth practices, and put pressure on
their healthcare practitioners to provide the safest birth options
for their babies and themselves," says Geradine Simkins, President
and Interim Executive Director of the Midwives Alliance. The
Midwives Alliance takes the position that the best interests of most
mothers and infants are served when women are given the opportunity
to birth under their own power and in their own way with the
intention of avoiding primary cesarean deliveries and other
unnecessary interventions. An impressive body of research literature
shows that the midwifery model of care results in less intervention
in the birth process and safe and satisfying outcomes for mothers
and babies. In addition, evidence shows that birth in a woman's home
with a trained midwife, or in a freestanding birth center, results
in decreased cesarean sections and other obstetrical interventions.
"We want women to have all the choices they need to have healthy
pregnancies and give birth safely," say Simkins, "and we are pleased
that ACOG's new guidelines on VBAC will add another choice to the
menu of maternity care options."
View
MANA's statement:
HERE
'Behold, I will bring them from the north country, And gather them
from the ends of the earth,
Among them the blind and the lame,
The woman with child and The one who labors with child, together,
A
great throng shall return there...And My people shall be satisfied with My goodness, says the LORD.'
Jeremiah 31:8, 14~~~
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October 2010
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