New VBAC Guidelines

I’m not going to lie when I saw the first article summary on the American Congress of Obstetrics and Gynecology’s (ACOG) new Vaginal Birth after Cesarean (VBAC) guidelines I cried. You see, last year I myself became a VBAC mama when I gave birth to my daughter Becca. I was ‘lucky’ with my VBAC as I was considered a ‘good’ candidate. I had a low transverse scar and my cesarean was a result of breech twins (a ‘condition unlikely to repeat’ as they told me) so I was able to find a supportive provider fairly easily. Reading this press release brought back so many of those emotions though. The way I felt when I first consulted my Obstetrician from my boys’ birth about my VBAC options. I remember his words so vividly “We certainly could try a Trial of Labor (TOLAC). When they work it tends to be fine, but when it goes wrong it is catastrophic. You wouldn’t want to risk your baby and your own life for something that probably won’t work out anyway would you?” or how I felt every time some well-meaning stranger would tell me that I could be killing my baby or orphaning my children as a result of my ‘selfish’ desire to have a vaginal birth. The self doubt, the fear, it all came flooding back to me. We knew that research supported our choices. We knew that we were making the safest choice for our children; the ones already here, the one still in my belly and any future ones to come. However when the ACOG, a respected medical organization’s own policy didn’t fully support VBAC how could I convince a layperson of why this truly was the safest choice?

So when I read that the ACOG was revising its policy I wanted to jump up and down in the streets. Finally, I would have people understand that VBAC really was a safe option! The press release stated how some cases that had previously been counter indicted for a Trial of Labor after a Cesarean (TOLAC) were now to be permitted. I was over the moon delighted. I had watched my friend Katie who struggled to find a provider to allow a TOLAC because she had two previous cesareans. She showed up at the hospital at 7 cm and argued with the staff until that baby was born several hours later. I knew of Michelle, who had a cesarean with her first due to a breech baby who was coerced into a second with her twins because, a ‘twin vaginal birth would stress the scar too much’. I even thought of Cassidy, a farmer’s wife in rural Nebraska who was told she couldn’t have a VBAC because the hospital wasn’t equipped for an emergency cesarean. I cried in joy when I thought of all the Katies, Michelles and Cassidys in the country who now have a concrete policy statement to bring to their care provider stating that their own professional organization now deems a TOLAC a viable option in their cases.

So it was with much enthusiasm and optimism that I started to delve into the actual practice bulletin.  There are several subtle changes in this bulletin that will make a major impact. Word choices and phrasing are significantly more positive. This creates a subtle air of approval instead of disapproval. There is also a significant emphasis on a woman’s choice being the key.

The Good

· Women with two prior cesareans are considered ‘reasonable’ candidates for a TOLAC–This is amazing. Women like Katie should no longer have to go underground to find a supportive healthcare provider.

· “Although chances of success may be lower in more advanced gestations, gestational age of greater than 40 weeks alone should not preclude TOLAC” What a victory! Since many women carry babies past 40 weeks (and a reason my original OB stated that I would need a cesarean at 40 weeks) it is a major ‘win’ that it is not counter indicted.

· “The limited number of studies that have evaluated TOLAC in women with prior low vertical uterine incisions have reported similar rates of successful vaginal delivery compared with women with a previous low transverse uterine incision” and health care providers and “patients may choose to proceed with TOLAC in the presence of a documented prior low vertical uterine incision” Love this point as well. Women with ‘special’ scars should be allowed to make the same risk/benefit analysis that anyone else can.

· While they still recommend that TOLAC be done at a hospital where an emergency cesarean can be completed in the case where this is not a possibility they state “Respect for patient autonomy supports that patients should be allowed to accept increased levels of risk, however, patients should be clearly informed of such potential increase in risk and management alternatives.” This is the greatest quote in the whole guidelines as far as I am concerned and any woman who is told by their provider they are not a good candidate should highlight this quote and bring it with them to their consult.

The Bad-There are a few items that while better, still show room from improvement.

· “Good candidates for planned TOLAC are those women in whom the balance of risks (low as possible) and chances of success (as high as possible) are acceptable to the patient and health care provider.” So even when the mother feels the risk is acceptable the provider still may disagree preventing a TOLAC. While in many places this simply means the woman ‘shops’ providers until she finds one who matches her beliefs, this may not be possible in rural locations where there is only one provider. Of course the mother could still reference the earlier quote on her having autonomy, this still will make the battle more difficult.

· “Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited” therefore they are silent on the issue. This is not as fabulous as endorsing it, but it’s not a prohibition either.

· The ‘big’ baby issue. Basically the bulletin is advising if the baby is born weighing more than 8.8 pounds (4000 grams) it is considered a big baby, making a less likely to have been a successful TOLAC, however the bulletin specifically says that “These studies used actual birth weight as opposed to estimated fetal weight thus limiting the applicability of these data when making decisions regarding mode of delivery antenatally” So basically it states a big baby might be a reason not to have a TOLAC however you won’t know if you have a big baby until after the baby is born. We all know the inaccuracy of ultrasound in determining baby size as it gets closer to delivery so really this addition will most likely result in more ‘Your baby is too big for VBAC” claims creating another obstacle for a TOLAC.

· As a mother of twins I like the twin recommendations but don’t love it. “Women with one previous cesarean delivery with a low transverse incision, who are otherwise appropriate candidates for twin vaginal delivery, may be considered candidates for TOLAC.” The ‘otherwise appropriate candidates part if the part that bothers me but that is another blog. In short what makes an appropriate twin vaginal birth candidate leaves something to be desired.

The Ugly–This is the part that I think completely missed the mark

“Conversely, those at high risk for complications (eg, those with previous classical or T-incision, prior uterine rupture, or extensive transfundal uterine surgery) and those in whom vaginal delivery is otherwise contraindicated are not generally candidates for planned TOLAC.” There are several things that are disagreeable about this sentence. First off the Landon (2004) study states a risk of rupture of 1.9% for VBAC after Inverted T, J or classical cesarean. Many women feel because of this that the balance of risk and chance of success is acceptable and this statement will make this a more difficult route for them. It does state next that “Individual circumstances must be considered in all cases, and 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.” Which I’m reading as ‘We won’t approve you for a TOLAC during your pregnancy but if you are so stubborn that you show up in active labor we won’t illegally cut you” This will lead to women planning a TOLAC to be subversive in their plans to ‘show up pushing’ and can create an atmosphere of distrust between the care provider and the mother.

Other issues touched on:

Inductions/Augmentation: This pretty much is unchanged“Misoprostol should not be used for third trimester cervical ripening or labor induction in patients” The biggest thing I’m seeing here is that “Induced labor is less likely to result in VBAC than spontaneous labor” this is the same case in any vaginal birth, anytime you add the induction or augmentation piece your chance of cesarean increases versus allowing labor to progress on its own timeline. They do state that “The varying outcomes of available studies and small absolute magnitude of the risk reported in those studies support that oxytocin augmentation may be used in patients undergoing TOLAC.”

External version to turn a breech baby: “The chances of successful external version have been reported to be similar in women with and without a prior cesarean delivery.” I would like to see some analysis of simply leaving the baby and birthing the baby breech in regards to a vaginal birth, but once again that’s another blog posting.

Epidural: “No high quality evidence suggests that epidural analgesia is a causal risk factor for an unsuccessful TOLAC”. I really wish they had gone one step forward here and added information on the effect that the epidural has on vaginal birth in general. I think it does a bit of a disservice to women to claim that an epidural is not a factor in cesarean rates when it has been found depending on when it is giving to “more than doubles the probability of receiving a cesarean”(Klein, 2006)

Overall it is clear this practice bulletin is leaps and bounds in advance of the old one. It promotes much more positive language, suggests providers present a more balanced overview of the options, and allows many more women encouragement to have a TOLAC. While this piece of paper isn’t going to be all that is needed to change policies all around the country it does provide a place to start. For all those mothers who were told inspite of current research that their plans of VBAC were selfish and dangerous I say thank you to ACOG for listening to research, listening to voices of experience and most importantly listing to mothers. I hope your members will do the same.

Kristen is a counselor, doula and childbirth educator working in Omaha, Nebraska. She is the mother of three children, three year old twin boys Alex and Nate and her VBAC baby Becca, 1 year.