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.

ACOG Issues NEW VBAC Guidelines

Here’s a link until I can get my hands on the whole set of guidelines…:

ACOG Issue Less Restrictive VBAC Guidelines

ICAN Responds to ACOG VBAC Guidelines

Thoughts on Informed Consent, Refusal and VBAC

If you’ve been listening to the news lately, you’ve probably heard a lot about vaginal birth after cesarean (VBAC). The NIH held a consensus meeting to decide what was appropriate in VBAC care. The general thought was that the overall VBAC rate should increase and that the rate of primary cesareans should decrease due to the risks of surgery to the baby and mother. The panel had several recommendations that can be boiled down into:

• 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

VBAC Consensus Statement (Draft)

The draft version of the NIH VBAC Consensus statement is up at: http://consensus.nih.gov/2010/images/vbac/vbac_statement.pdf

PR: wait… I: wait… L: wait… LD: wait… I: wait… wait… Rank: wait… Traffic: wait… Price: wait… C: wait…

VBAC from a Care Provider’s Perspective

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What is it really like to be a hospital care provider attending VBACs? Janelle from Birth Sense describes it in this post submitted to the ICAN VBAC Blog Carnival.

The whole post provides a very rational, no nonsense description of the actual problems that care providers face without an emotional “WE’RE ALL GOING TO BE SUED AND EVERYONE IS GOING TO DIE AND YOU JUST DON’T UNDERSTAND RISK!” She calls upon providers of modern obstetrics to “speak up on behalf of women who want VBAC and insist that realistic, evidence-based guidelines are instituted.”

Furthermore, Janelle points out something that would probably shock the public about hospitals. The “special” mandate that an OB remain in the hospital during the entire VBAC labor with an operating team standing by is hypocritical. If hospitals are so serious about having a team ready to handle VBAC-related emergencies, why would they not want to have the same safety net available to deal with comparable emergency scenarios in “low-risk” women? When I gave birth in a hospital for the first time, I mistakenly assumed that there was an OB and an operating team on hand for those rare emergencies. Why else would I have been in a hospital?

What is most perplexing to me is the mandate that the provider remain in the hospital during a VBAC labor “just in case”, yet other serious causes of perinatal morbidity and mortality are not considered adequate reason to have a surgeon and operating team standing by.  Some examples are:

1. Cord prolapse, with an incidence of 0.14-0.62 percent.  This can cause permanent fetal injury or death.¹
2. Placental abruption, with an incidence of 0.6 percent.  Again, this complication of labor can cause permanent fetal injury or death, as well as potentially life-threatening blood loss for the mother.²
3. Placenta accreta, and its variations (placenta increta and placenta percreta).  With a reported incidence of as many as 1 in 533 births, this is a serious maternal complication which can cause death.³

If we are serious about being able to take immediate action in the event of uterine rupture (approximately 0.5% incidence in low-risk labors VBAC labors), we should be equally serious about being prepared to immediately manage other perinatal emergencies.   The truth is, VBAC is not much riskier than a normal first birth, provided a few criteria are met:

• One low transverse uterine scar
• Normal onset of labor, no cervical ripening or induction
• No use of pitocin augmentation during labor
• Prior vaginal delivery increases chances of successful VBAC
• At least 18 months since cesarean birth

The risk associated with VBAC that concerns hospitals, insurance companies and care providers isn’t just the potential risk to women and babies. They are naturally concerned about the risk to their financial bottom line associated with a potentially predictable obstetric emergency.

The next time you hear anyone try to tell you that patients or laypeople just don’t understand risk, the question should be “The risk to whom?” I would argue that, given accurate information and percentages, most patients understand risk just fine. When you read between the lines, it’s clear that patients are expected to believe that the risk that lies behind scare tactics and lies about necessity of many cesareans and inductions is based on a certain risk to them or their baby. Unfortunately, it often has little or nothing to do with risk to the patient and everything risk to the care provider or institution.

And that’s the risk that most patients do not understand about how decisions are made about their bodies until it’s too late.

VBAC Varies by Hospital Type

From The Feminist Breeder

Adverse Outcomes Compared to VBAC

This shows a slide from the NIH VBAC Consensus webcast, taken by Gina at The Feminist Breeder. It talks about how VBAC compares to other adverse outcomes in perinatal period.

NIH VBAC Consensus Conference is live NOW

You can watch it at: http://consensus.nih.gov/2010/vbac.htm

VBAC is Vital

Vaginal birth after cesarean (VBAC) is a crucial option in maternity care today. I see VBAC as one of the key ways for us to attack the growing maternal mortality.

Many people do not think about the cesarean rate as a two-part issue. There is the primary cesarean rate, the number of women having their first cesarean. There is also the secondary or repeat cesarean rate. Currently, both numbers are growing.

The primary cesarean rate is growing for many reasons. Some of these reasons women can help control, like choosing practitioners who have faith in the process and only intervene when truly necessary. A good example of an intervention that can increase the cesarean rate and isn’t truly needed would be non-medical inductions.

But the secondary cesarean rate is where VBAC comes in. This rate is growing as well, largely because women are not being offered the ability to give birth vaginally after a previous cesarean. The growing body of research is showing that VBAC is safe and successful for more women who try it. Many women want to try it but are turned away by their doctors or midwives – leaving them the option of a repeat cesarean or fighting for a VBAC.

More and more women are choosing to fight for the VBAC. The question becomes – why should women have to fight for something that is likely to be safer for her and her baby?

This is part of the ICAN Blog Carnival.

But Why is VBAC so Important?

I am sure that I am not the only person to ask myself this with the announcement of the National Institute of Health VBAC Conference announcement.  But unlike most, I know more than my fair share about VBAC after having a cesarean with my first child it became more than a healthy obsession to me. But sadly the more I learned, the more sad I became about the access to VBAC nationally.

In a 2009 survey from The International Cesarean Awareness Network, it was found that nearly 50% of all hospitals in The United States has some sort of a VBAC Ban in place. Whether it be a formal policy written by hospital administrators, or a de facto ban, meaning there simply are no providers who will take on a patient who wishes to have a Vaginal Birth after Cesarean.

But what does this mean for women nationally? For the women who have had cesarean sections, whether medically necessary, or unnecessary?  It means that once they have experienced once cesarean birth, they have no choices regarding future pregnancies or deliveries. Essentially leaving them with no real informed consent.  To me, as a huge activist, that is not only a violation of a patients rights, but it is a major human rights and bodily anatomy violation.

Right now, 90% of women who have had one cesarean section will go on to deliver all of their children through multiple major abdominal surgeries, the next more risky than the last. When the safe and relatively low risk  option of a VBAC is not available.  But lets look at the numbers regarding the risks of VBAC as opposed to repeat cesarean sections.
The major risk associated with a Vaginal Birth after a Cesarean section is something most near the most not knowing the risk is so low. Uterine Rupture.  Not something we should discount or not worry about, but when we look at the statistics, the average healthy woman who has had one previous cesarean section has a 0.6% chance of experiencing a uterine rupture.

When I went through the process of filling out and signing my VBAC consent form for my second pregnancy, there was paragraph after paragraph panting VBAC in a scary pictre, then a small paragraph with the minor risks of a repeat cesarean, almost like the practice of Obstetricians backing my midwives wanted me to change my mind and run in fear.
This form was not informed consent by any means, it was skewed, biased, and provided misinformation, but sadly this is what we are seeing Nationwide today.

But I can hope with the NIH VBAC conference we can start to see a change in the way that VBAC is handled nationally.
Women have the right to real informed consent, and give birth vaginally if that is what they choose for their own birth.

For more information on Cesarean Awareness, and Advocacy, check out The International Cesarean Awareness Network.