New guidelines less restrictive on birth options

Vaginal birth after a Cesarean, or VBAC, is a safe and reasonable option for most women – including for some women who have had two previous cesareans – according to the nation’s leading group of professionals providing health care for women, the American College of Obstetricians and Gynecologists, or ACOG. Their updated, “less restrictive” guidelines on VBAC were released last week.

Members of ACOG, as well as many health practitioners and advocates from all over the country were present at the National Institute of Health’s “VBAC: New Insights” conference this March in Maryland. The conference sparked a conversation many in the birth world deemed necessary and timely.

“The current cesarean rate is undeniably high and absolutely concerns us as ob-gyns,” said Dr. Richard N. Waldman, president of the ACOG. “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,” Waldman said, “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.”

The cesarean delivery rate in the U.S. has increased dramatically in the past 40 years, from 5 percent in 1970 to more than 31 percent in 2007. The “once a cesarean, always a cesarean” mantra was the norm until the 1970s, when VBACs started to become more common.

The peak of VBACs was in 1985, when they were at about 28 percent of births, but afterward they began a steady decline to the less than 10 percent (8.5 percent in 2006) of today. ACOG attributed that decrease to “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.”

Birth advocates are hopeful that the new guidelines mean change.

“ACOG’s updated recommendations for VBAC are much more in line with the published medical research and echo what ICAN has said for years,” said Desiree Andrews, president of the Internal Cesarean Awareness Network, ICAN. “The benefits of VBAC cannot be overstated, and if ACOG is truly ‘serving as a strong advocate for quality health care for women,’ then this is a long overdue action on their part.”

Andrews went on to say that ICAN hopes ACOG’s new guidelines will enable women to find the support and evidence-based care that they need and deserve.

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

The primary change in the 1999 guidelines was the need for medical personnel to be “immediately available,” on site at the hospital. Previous guidelines called for personnel to be “readily” available, meaning not more than 30 minutes away. But the need for “immediately available” medical personnel is still noted in the updated guidelines. However, there are also clearer guidelines for what to do when “immediately available” just isn’t possible, as is the case with many smaller, rural hospitals.

Because uterine rupture – a feared complication of VBAC, even while the chances are slim, at between 0.5 percent and 0.9 percent – can be an emergency situation, the ACOG maintains that a trial of labor after cesarean 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 Waldman. “Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.”

They also maintain that guidelines should not be used to force a woman to have a repeat cesarean delivery against her will and say that if a physician is uncomfortable during prenatal care, they have every right to refer the woman to another physician or center.

As for what that means to local moms, it could mean not much change, unless they push hard to advocate for themselves.

Wallace Hudson of Beebe Medical Center Corporate Affairs said they have had no discussions on the topic and plan on “keeping things the way they are.” He explained that Beebe doesn’t have a specific “policy” against VBACs but rather has a “practice” of not supporting them. Many times, local patients are referred to Christiana Care in Newark, and it is up to the individual patient to decide whether to change hospitals and/or providers. (In 2008, Beebe had 1,036 births. Just seven were VBACS).

Beebe does not have 24-hour anesthesia capabilities or 24-hour operating room capabilities, the two items, along with a physician being on site during labor, that earlier guidelines dictated were necessary, which for many smaller hospitals often resulted in a “no VBAC” policy or outright written bans on them.

According to ICAN, in 2009, chapter volunteers contacted more than 2,800 U.S. hospitals to determine what their VBAC policies were. Of those, nearly one in three had formal policies forbidding VBAC. One in five had no doctors on staff willing to accept a patient planning a VBAC.

ICAN representatives said they maintain that the statements condemning VBAC bans within the revised VBAC Practice Bulletin provide some hope that ACOG will now take an active role in “reversing the damage done” by previous guidelines.

Peninsula Regional Medical Center (PRMC), in Salisbury, Md., which does have 24-hours-a-day operating room and anesthesia capabilities, has traditionally not had many physicians interested or able to stay on site during labor for their VBAC patients, resulting in a VBAC average far less than the national average of 8.5 percent. (In 2008, PRMC had 2,235 births. Just six were VBACs.)

Because they have always had the resources to quickly respond to an emergency birth, and to be within ACOG guidelines, Regina Kundell, director of Women’s and Children’s Services at PRMC, said the new practice bulletin from ACOG likely won’t change much as far as that hospital is concerned.

She did say that, now that the eligibility of women seems to have been widened to a bigger group – including some women that have had two C-sections and women that are VBACing with twins – it could affect how the doctors look at it.

“We do VBACs, and we’d love to see more happen,” said Kundell. “It looks like maybe they are willing to open it up to more women. Hopefully, this will affect the doctors and make them more eager to offer it.”

She said the hospital is equipped with the 24-hour anesthesia and operating room, and can be ready for the infrequent chance that a uterine rupture occurs, where an emergency C-section is necessary, as long as the physician is nearby – but they “don’t always want to be.”

“If [physicians] get some more pressure from women, as the women become more informed as consumers, they may request it more,” Kundell said.

She also said that, with purposeful policies regarding eliminating elective early inductions (before 39 weeks) among other labor management changes, the hospital’s primary C-section rate has gone down and is now holding steady. Education of the consumer is key, she added.

ICAN’s Andrews couldn’t agree more, saying that ICAN encourages all women to take the lead in decision-making about care during pregnancy and childbirth.

“It is only with continued pressure from the consumer that necessary change in maternity care will happen. 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,” Andrews said. “This is a first step in returning to women an appropriate respect for patient autonomy.”

For more information on C-section and VBAC rates (up to 2008) for all Delaware hospitals and Peninsula Regional Medical Center in Salisbury, visit http://www.bethanybeachnews.com/files/vbactable.pdf online.

Women who are seeking information about how to avoid a cesarean, have a VBAC, or who are recovering from a cesarean can visit ICAN online at ican-online.org.