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ACOG issues less restrictive VBAC guidelines

Wow, Practice Bulletin No. 115, replacing No. 45 is a breath of fresh air.  No. 45 included the infamous “immediately available” phrase resulting in a fire of VBAC bans to rage around the country, but primarily in rural areas.  Surely No. 115 is in response to the NIH’s March 2010 VBAC conference and the VBAC Statement it produced.

In short, VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.  Being pregnant with twins, going over 40 weeks, having an unknown or low vertical scar, or suspecting a “big baby” should not prevent a woman from planning a VBAC (ACOG, 2010).

What follows is a brief overview of these new guidelines.

They express support for VBAC after one and two prior cesareans:

Attempting a 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.

They express support for VBAC with twins or unknown scars:

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.

They say a Pitocin induction remains an option:

Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC [trial of labor after cesarean...Misoprostol [Cytotec] should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.

They detail the risks that can come with multiple cesareans which are often not listed in your standard “informed consent” document:

[VBAC] 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).

But what will have the most impact on the most women is the lifting of the “immediately available” recommendation turned requirement as suggested by the NIH VBAC Conference:

The [American] College [of Obstetricians and Gynecologists] 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.

They acknowledged how the phrase “immediately available” in their last recommendation were used to support VBAC bans:

“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.

And they now support hospitals who do not meet the “immediately available” standard attending VBACs:

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.

Finally, they assert how women should not be force to have a repeat cesarean against their will and that women should be referred out to VBAC supportive practitioners if their current care provider would rather not attend a VBAC:

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.

Removing the “immediately available” standard while supporting VBAC with twins, after two prior cesareans, and with unknown scars is a huge step in the right direction.  It seems that the option of VBAC is now available to hundreds of thousands of women, many of whom, up to this point, were left with no choice at all.

Read the whole press release dated July 21, 2010: Ob-Gyns Issue Less Restrictive VBAC Guidelines.

Download the PDF: Practice Bulletin #115, “Vaginal Birth after Previous Cesarean Delivery,” is published in the August 2010 issue of Obstetrics & Gynecology.

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.

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19 comments to ACOG issues less restrictive VBAC guidelines

  • Hey Jen –

    I just wanted to drop a line to let you know that I saw your hello comment on my blog, and that I’ve been reading your stuff for a very long time! I was inspired by Gina’s most recent post to come over and say thank you for all your hard work for VBACing moms.

    Yours,
    CM

  • I agree that this bulletin is more sophisticated than the one it replaces (which is 54 by the way, not 45), but it isn’t enough for ACOG to just back pedal and issue a new bulletin. The original “immediately available” bulletin had a huge impact on hospital policies, medical practice and women’s health.

    As I said in my own blog entry about this issue, there is going to have to be a more deliberate effort to dial the cesarean rate back from where it is than what can be expected from the issuing of a practice bulletin such as this.

    Thanks for such a great site!

  • I covered the new ACOG guidelines (and in particular, the changes about VBA2C) on my blog.

    http://wellroundedmama.blogspot.com/2010/07/about-damn-time-good-news-for-vaginal.html

    I agree that they have a long way to go to eradicate the harm that came from the “immediately available” change and they have GOT to be more aggressive about preventing more primary cesareans in the first place.

    Good to see you blogging again, Jen.

    • Jen Kamel

      Thanks Kmom! It’s been hard to manage it with my adorable children pulling at my skirt, but this was to big not to mention!

  • [...] the American College of Obstetricians and Gynecologists (ACOG, 2010), VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.  Being pregnant with [...]

  • sp80

    I know Im reviving an old thread here, but I am working on conceiving another child and want a vbac when I get pregnant. My first pregnancy was almost 14 years ago. I was pregnant with twins and wound up having a c-section due to premature rupture of membranes at 26 weeks. My next pregnancy (over 4 years ago)was a c-section because the doctor insisted that I have one due to unknown type of incision(didnt know I had other options at the time). I tried to get my records recently and found out that the records were held onto for 10 years and are now gone. My obgyn said he couldnt get the records at the time but it was only about 9 years since my first delivery so I’m thinking he lied about my records not being found. He is sort of known as the c-section king where I’m from. What I want to know is if there is less chance of rupture as time goes by, and would I be a good candidate for vba2c. Thanks

    • Jen Kamel

      Sp80,

      The limited data we have on the rates of rupture in a classical incision vs. a low transverse incision reveal that the differences are significant. I personally wouldn’t attempt a VBAC after what could be two prior classical incisions. If I felt very strongly about it, I would find a hospital-based provider. You can always look for the two most VBAC supportive OBs in your area and review your medical records from your second surgery together and get their opinions.

      I’m sure you will find many people on-line to support you if you decided to peruse a VBA2C. You just have to decide how much risk is acceptable to you. I like to know all the variables at play, but that’s me.

      The data we have on birth intervals is also not very strong because the studies have been rather small (less than 5,000 woman after a cesarean.) You can review an over here: http://vbacfacts.com/2011/11/11/birth-intervals-uterine-rupture/.

      Warmly,

      Jen

  • [...] the American Congress of Obstetricians and Gynecologists (ACOG, 2010), VBAC is a “safe and appropriate choice for most women” with one prior cesarean and for “some women” with two prior cesareans.  [...]

  • Thia McCauley

    Jen, first thank you for your site! I’m under the care of an OB who practices at a hospital that does not “allow VBACs” but has stated the only way to deliver at said hospital is to show up in labor & pushing. Quoting from your site quoting the ACOG bulletin :
    “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.”
    If a patient (Me 3 prior sections), presents one’s self in labor at said hospital and declines a section, the hospital then has to heed the wishes of the patient? Am I understanding this correctly? Does the hospital have the right to stop contractions and section the patient? This is what I’m hearing in my birthing community and I really cannot believe a hospital would/could do that.

  • Stephanie Fuhrmann

    In this article it says “They say a Pitocin induction remains an option:
    Induction of labor for maternal or fetal indications remains an option in women undergoing TOLAC”

    I read through the Bulletin no. 115 and could not find this listed – I found where it says “However, due to variation among studies with respect to indications for delivery, induction protocol, agent and dose, and subsequent use of oxytocin, it is difficult to identify an absolute risk of uterine rupture associated with induction.” This isn’t quite the same as saying that petocin is an option.

    I am currently with an OB that seems very VBAC friendly, but says she will not use petocin, even a small dose in conjunction with a foley cathether. As I am now overdue, my concern is that if I do not spontaneously go into labor, that I will have no option but to schedule a c-section. Where can I find this information on VBAC petocin induction to try to persuade my OB to consider a low-dose petocin induction (assuming that every other aspect of mine and baby’s health and the pregnancy looks healthy)? Thank you SO MUCH.

    • Jen Kamel

      Stephanie,

      On page 454 under the heading “Induction and Augmentation of Labor,” ACOG states, “Induction of labor for maternal or fetal indication remains an option for women undergoing TOLAC” and then goes on to discuss several studies which illustrate that Pitocin has lower rupture rates than prostaglandins. ACOG also states that Cytotec is contraindicated in VBACs here, “Evidence from small studies show that the use of misoprostol [Cytotec] in women who have had cesarean deliveries is associated with an increased risk of uterine rupture. Therefore, misoprostol should not be used for third trimester cervical ripening or labor induction in patients who have had a cesarean delivery or major uterine surgery.”

      Some OBs don’t like to induce, others are ok with it. ACOG says it “remains an option.” Unfortunately, when OBs do not wish to induce, moms are left with no choice.

      You can chat with VBAC supportive OBs over on the VBAC Facts Community.

      Warmly,

      Jen

  • [...] Read, be familiar with, and bring a copy of the 2010 ACOG VBAC guidelines. [...]

  • Lauren

    Hello. I am looking for information on unmedicated VBACs. My OB just told us (I’m 30 weeks) that I have to have an epidural immediately upon entrance to the hospital because that is the only way the hospital can ensure the cath was inserted correctly. I wanted to go without drugs because I am afraid I won’t be able to push adequately on medication and it will lead to another c-section.

    • Jen Kamel

      Lauren,

      VBAC supportive OBs do not require epidurals or any kind of pain relief. The fact is, in a true emergency, they would put you under general anesthesia, they would not be fiddling with a spinal. If the cesarean is not an emergency, then there is time to properly place a spinal. You can legally decline anything, however, your OB might make things difficult for you if you don’t comply. Can you switch OBs?

      Warmly,

      Jen

  • [...] latest 2010 VBAC Practice Bulletin No. 115 produced by the American Congress of Obstetricians & Gynecologists (ACOG) asserts: Induction [...]

  • […] Effective immediately, the birth centers accredited by the CABC may offer TOLAC* to all women who have had one previous cesarean, a low, transverse scar, and favorable placental location (not low-lying or over an old scar).  Previous policy made it an option only for women who had already had at least one vaginal birth after Cesarean, and only at facilities that could demonstrate 24/7 obstetric and anesthesia care available in close proximity, as per the recommendations of the American College of Obstetricians and Gynecologists (ACOG). […]

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