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.

ACOG Issue Less Restrictive VBAC Guidelines

ICAN Responds to ACOG VBAC Guidelines

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

The use of medical technology in the rare instance of a complicated birth is a blessing, but the flip side is that overuse of the exact same technology is a curse.? The use of fetal monitoring has done nothing but increase the cesarean rate.? Don’t believe me?? Ask ACOG.? We routinely give women IVs, fetal monitoring and the cesarean surgery rate has gone up 46% in 10 years.? Something is wrong.? That is the misuse of medical technology in a typically uncomplicated process.? When cooking, do you skip the blender because you know how to chew your food?? Or do you process all your food into liquid in case you might choke on a piece of it?

Here are some ways to avoid unnecessary interventions in birth:

• Consider where you are giving birth. Giving birth at home or in a birth center will help ensure that you are well supported in an uncomplicated pregnancy.? Unnecessary technology is not available because it is not needed.? Emergency equipment is saved for emergencies.

• Consider with whom you are giving birth. Giving birth with a midwife at home, a birth center or even a hospital could have beneficial effects on your labor by the lack of unneeded technology.? There are certainly OBs and family practitioners who provide quality, low risk care without overusing medical technology, but they are not trained in the specialty of low risk women.

• Frequent conversations about your needs. Talk to your practitioner about what you need both in terms of support and (in)action from them.? Ask them when they would resort to medical technology and open up that conversation.? Remember, the point is not that intervention is bad but that unnecessary intervention is harmful to labor, baby and mom.

• Don’t hesitate to change. So many women get into their pregnancies and realize that either they’ve changed their goals or that their practitioner is not supportive.? Some choose to have home births, some choose to go to a different facility or different provider.? That is an acceptable thing, do not be concerned about hurting your practitioner’s feelings.? If your plumber provided services that were not what you needed would you hesitate to find a new one? Or live with a broken faucet?

Trying to tell if a medical intervention is necessary?? Talk to your practitioner.? Over the course of your prenatal care, your relationship has grown and you need to trust this person in practice and philosophy.? Get informed consent.? Do you have time to think about it and discuss it or is this an emergency? Do you know why a test or procedure is being proposed? What is it supposed to so?? When will you know if it worked?? Are there other procedures, tests or possibilities?? What are the benefits?? What are the trade offs? What happens if you decide to do nothing or not go forward with what they are proposing?? If you determine, with the help of your medical team, that an intervention is necessary and not “just because we do it to everyone,” then you are still keeping with the spirit of this healthy birth practice.

Lamaze Healthy Birth Practice | Mothers Advocate Video | Mothers Advocate Handout

ACOG Releases 2009 Medical Liability Survey

Results Paint Dismal Reality for Ob-Gyns and Their Patients

While this is a group that usually likes to stick their heads in the sand when it comes to the women that they care for, I was surprised at the honesty about the OB-GYNs that they serve. ?I know ACOG has been concerned about the number of doctors who are leaving obstetrics, but this actually breaks it down and shows you the drop in doctors offering VBACs, how many are being sued, etc. ?The most startling tale? ?They admit that it harms the patients…

And why are they not doing VBACs, seeing high risk patients and providing better care? ?I think they say it best:

“Of the survey respondents who reported making changes to their obstetric practice as a result of the risk or fear of professional liability claims or litigation, 30% decreased the number of high-risk obstetric patients that they accepted. In addition, 29% reported performing more cesarean deliveries, and 25.9% stopped offering/performing vaginal births after cesarean (VBACs). An additional 13.9% decreased the number of total deliveries.”

Litigation. ?Perhaps the power cry from the women shouldn’t be “Keep your scalpels off my body!” but rather, “I’ll promise not to sue if you practice evidenced based medicine.”

• Soda
• Fruit juice without pulp
• Sports drinks
• Coffee
• Tea

They still say that women having a planned surgery, be a it a cesarean birth or a tubal ligation after birth may need to be restricted on a case-by-case basis. ?This also goes for women who are obese, having diabetes, etc.

While I’m glad to see that they are encouraing women to drink in labor, it’s been a long time coming. ?Even the American Society of Anesthesiologists has been saying this for a long while. ?As for food, ACOG still gives a big thumbs down despite the known benefits of food in labor for mothers who want it.

Hopefully this boost will make it’s way to a labor and delivery unit near you someday soon.

• Wait until 39 weeks or do fetal lung maturity testing
• Use cervical ripening before full blown labor induction
• Do not use Cytotek on someone with one prior cesarean
• Induction reasons may be for physical reasons with mom or baby or other reasons that are reasonable, like distance from hospital in a rural area
• There are risks to induction
• There are some reasons induction is not an option (placental, fetal position, etc.)

What are your thoughts on labor induction? One thing that jumped to my mind was that they said labor induction had doubled since 1990 and that now 1 in 5 women were induced. That number sounded really low to me.

The study of more than 24,000 full-term infants found that those delivered at 37 weeks to mothers who had elective repeat C-sections were about twice as likely as newborns delivered at the recommended 39 weeks to experience breathing problems, bloodstream infections and other complications. Babies born at 38 weeks were 50 percent more likely to have problems; the risk was about 20 percent higher just a few days early.

The article states that the rate of cesareans is now over 30%, and that there is a great deal of debate as to why this is.? However, they then go on to say:

Although a pregnancy is considered full term after 37 weeks, the American College of Obstetricians and Gynecologists recommends that elective repeat C-sections occur no earlier than 39 weeks to make sure the baby has fully developed. But some women opt to deliver a little earlier for a variety of reasons, including being eager to see their baby, being tired of pregnancy or for convenience.

The article here suggests, with no data or studies to back it up, that the women themselves are convincing their OB’s to disregard their instructions from ACOG, go against evidence based care, and put the babies at risk in order to give in to the mothers whims.? I find it very curious that women hold so much power in this regard, when most other choices they make in childbirth in a typical hospital would be disregarded.? If doctors are so concerned for mothers choices, even when it means breaking their own rules and putting babies in harms way, then why aren’t the choices that women make for their labors and births that do not infringe on any rules or cause harm to their babies respected?? I doubt very much that doctors are truly allowing women to make an informed choice on this.? Perhaps women who are getting a repeat elective cesarean are showing an interest in an earlier delivery, but, are they then given the risks, benefits, or alternatives to delivering early?? Did they make a truly informed choice?? Or are they making a decision based on the belief that their baby is “full term” and is ready to be born?? In the absence of any cited study on the subject, it is my feeling that the article is making quite the presumption.

Here is all the study really had to say about the matter:

Of 24,077 women who gave birth through a repeat C-section between 1999 and 2002, 13,258 were clearly elective — meaning the researchers could find no evidence that the baby or mother was in distress or any other medical reason the woman could not attempt to deliver through labor. Of those, nearly 36 percent of the deliveries occurred before 39 weeks.

It is unclear from the study why there were so many “elective” cesareans performed.? It is not clear to me whether the researchers considered a repeat cesarean to be elective or not.? If the researchers didn’t consider a previous cesarean as a medical reason as to why the mother should have another one, then that would explain the large number of scheduled “elective” cesareans.? It doesn’t seem that any data was provided as to whether the mothers or the doctors were selecting the time in which these cesareans would be scheduled.

The articles goes on to talk about the findings in the study about the true risks of a scheduled cesarean before 39 weeks:

More than 15 percent of the babies delivered at 37 weeks suffered a complication, such as problems breathing, low blood sugar, infections or conditions that required intensive care, compared with about 8 percent of those delivered at 39 weeks. About 11 percent of those delivered at 38 weeks experienced complications. Babies born at 37 weeks were four times as likely as those delivered at 39 weeks to have breathing problems.

It seems very clear cut, but then another angle is presented:

While other experts agreed that the study provides important information to help women and their doctors make decisions about timing C-sections, some said the risks of complications are relatively low and need to be weighed against the small but not insignificant chance that waiting a week or two would result in more stillbirths.

The article does end with a voice of reason though:

But Spong said the magnitude of the risk of stillbirth from waiting is unclear, and the new study shows the risks of complications from early delivery is significant.

“It’s hard to advocate doing a Caesarean at 37 weeks to try to prevent a stillbirth when we don’t really know the true risk,” she said.

Overall, I feel this is a very good study that has been done.? Many babies and new parents will be saved the possible traumatic experience of the NICU.? Many doctors, who already had some research and guidance from ACOG to tell them not to schedule repeat cesareans before 39 weeks, will now have this additional comprehensive study that clearly shows the impact of doing so.? This also may bring to women’s and doctor’s consciousness that cesareans themselves are not perfectly safe for all involved no mater what.? They need to be carefully planned and managed and only performed in cases of true emergency, or they could possibly do more harm then good.