Thursday, July 22, 2010

ACOG Issues Less Restrictive VBAC Guidelines!!

This is huge news! The birth world is going crazy! The American College of Obstetricians and Gynecologists has issued less restrictive VBAC (Vaginal Birth After Cesarean) guidelines! And while they're not 100% perfect, they are an excellent step in the right direction.

Here is yesterday's press release, which explains the risks of repeat cesareans and provides a great overview of the changed thinking (
emphasis mine):
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.

TOL = trial of labor
TOLAC = trial of labor after cesarean

The guidelines are 9 pages long, so here is a bit of summary of the highlights:

"TOLAC should ideally consider the possibility of future pregnancies."

"The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC."

"...if, for example, a patient who may not otherwise be a candidate for TOLAC presents in advanced labor, the patient and her health care providers may judge it best to proceed with TOLAC."

"More than one previous cesarean delivery... given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC..." (this is a reversal of the 2004 VBA2C ban unless the woman had at least one prior vaginal delivery)

"Macrosomia (big baby)...suspected macrosomia alone should not preclude the possibility of TOLAC."

"Gestation beyond 40 weeks.....gestational age of greater than 40 weeks alone should not preclude TOLAC."

"Previous low vertical incision...patients may choose to proceed with TOLAC in the presence of a documented prior low vertical incision."

"Twin gestation....may be considered candidates for TOLAC."

"Induction and augmentation of labor...remains an option for women undergoing TOLAC."  (mixed blessing, they did say no Cytotec)

"External cephalic version (to rotate a breech baby) not contraindicated if a woman is at low risk of adverse maternal or neonatal outcomes..."

"Analgesia (painkiller)....for labor may be used as part of TOLAC, and adequate pain relief may encourage more women to choose TOLAC."

"Other elements of intrapartum management..."Most authorities recommend continuous electronic fetal monitoring.  No data suggest that intrauterine pressure catheters or fetal scalp electrodes are superior to external forms of monitoring..."

"Delivery...There is nothing unique about the delivery of a fetus or placenta during VBAC."

"What resources are recommended for health care providers and facilities offering a TOLAC?"
And here is where they loose points: They recommend facilities be capable of emergency delivery.  "ACOG...has recommended 'immediately available' some have argued that this...limits women's access to TOLAC...particularly in rural areas.  Restricting access was not the intention of the past recommendations...Although there is reason to think that more rapid availability of cesarean delivery may provide an incremental benefit in safety, comparative data...are not available.  ...the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care.  When resources for immediate cesarean delivery are not available, the College recommends that health care providers and patients considering TOLAC discuss the hospital's resources and availability of obstetric, pediatric, anesthetic, and operating room staffs."

They then go on to say if the setting is not ideal, the "best alternative may be to refer patients to a facility with available resources...or create regional centers...However, in areas with fewer deliveries and greater distances between delivery sites, organizing transfers or accessing referral centers may be untenable." (duh) 

"Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk
...Referral may also be appropriate if, after discussion, health care providers find themselves uncomfortable with choices patients have made.  Importantly however, none of the principles, options or processes outlined here should be used by centers...or providers or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option...Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women in labor who decline to have a repeat cesarean delivery."

The news world is buzzing with responses. A few reactions:

The International Cesarean Awareness Network (ICAN) says:

However, more than a revision of the VBAC Practice Bulletin is required to reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates. ICAN challenges ACOG to take an active role in educating both women and practitioners about healthy childbirth practices; practices that not only encourage VBAC but discourage the overuse of primary cesareans.

The LA Times

"But, no matter what the medical evidence says, whether the attitudes of doctors and women will change to favor a less-invasive and medicalized — as well as slower and less convenient — approach to childbirth remains to be seen.”

The NY Times

"Women’s health advocates praised the new guidelines because they expand the pool of women considered eligible for vaginal births, but they expressed doubts about whether the recommendations go far enough to change a decade of entrenched behavior by doctors, hospitals and insurers...

Maureen Corry, executive director of Childbirth Connection, an advocacy group, said, “Overall, it’s dubious that these guidelines will in fact open up access for women.”
Debra Bingham, president-elect of Lamaze International, an advocacy group for natural birth, said the “immediately available” wording might still pose an obstacle"

Gina at the Feminist Breeder writes about how the ACOG didn't come to this decision on their own in BREAKING NEWS: ACOG Admits What We Already Knew

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