Category Archives: ACOG

Thoughts on VBA3+C (VBAC after three or more prior cesareans)

Note regarding “TOLAC.”  When reading from medical texts, remember that you are no longer in the land of emotion and warm fuzzies.  Rather, envision that you have been transported to another world, a clinical world, where terms like TOLAC/TOLAMC, or trial of labor after (multiple) cesareans, are used.  I don’t think that most care providers understand the emotional sting that many women seeking VBAC associate with the term TOLAC.  It’s important for women to understand the language care providers use so that they can translate TOLAC into “planning a VBAC” and not feel slighted.  You might want to read this article which describes what the term TOLAC means, how it’s used in medical research, and why it’s not synonymous with VBAC.

________________________________

A mom recently asked, “Does anyone have some facts on VBA3C?”

I provided this collection of info…

Who makes a good VBAC/VBAMC candidate?

ACOG’s 2010 VBAC recommendations affirm that VBA2C (vaginal birth after two cesareans) is reasonable in “some” women.  Between what they say about VBA2C and who is a good VBAC candidate, we might be able to discern who might be a good VBA3+C (vaginal birth after three or more cesareans) candidate. (For a really great, though growing outdated, review of the VBAMC research click here.)

A couple things to keep in mind while reading…

Reason for prior cesarean/history of vaginal birth.  Like women with one prior cesarean, I would suspect that women who have had cesareans for malpresentation (breech, transverse lie, etc) and/or a history of a prior vaginal delivery would have the highest success VBAMC (vaginal birth after multiple cesarean) rates.  In women with one prior cesarean, the average success rate is about 75%.  This increases to over 80% among women who had their cesarean for malpresentation and/or a history of a prior vaginal delivery.

Scar type.  Low transverse incisions (also called bikini cuts) carry the lowest risk of rupture in comparison to classical, high vertical and T/J incisions.  With the likely increased risk of uterine rupture in a VBAMC (we don’t have a lot of great data for VBA2C and even less so for VBA3+C), I think having low transverse incisions would be ideal.

kids-playing-on-see-saw

Here ACOG describes the qualities of a good VBAC candidate:

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. The balance of risks and benefits appropriate for one patient may seem unacceptable for another. Because delivery decisions made during the first pregnancy after a cesarean delivery will likely affect plans in future pregnancies, decisions regarding TOLAC should ideally consider the possibility of future pregnancies.

Although there is no universally agreed on discriminatory point, evidence suggests that women with at least a 60–70% chance of VBAC have equal or less maternal morbidity when they undergo TOLAC than women undergoing elective repeat cesarean delivery (62, 63).  Conversely, women who have a lower than 60% probability of VBAC have a greater chance of morbidity than woman undergoing repeat cesarean delivery. Similarly, because neonatal morbidity is higher in the setting of a failed TOLAC than in VBAC, women with higher chances of achieving VBAC have lower risks of neonatal morbidity.  One study demonstrated that composite neonatal morbidity is similar between TOLAC and elective repeat cesarean delivery for the women with the greatest probability of achieving VBAC (63).

The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC.  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.  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.

What does ACOG say about VBA2C?

In its latest VBAC recommendations, ACOG specifically addresses VBA2C:

Studies addressing the risks and benefits of TOLAC in women with more than one cesarean delivery have reported a risk of uterine rupture between 0.9% and 3.7%, but have not reached consistent conclusions regarding how this risk compares with women with only one prior uterine incision (64–68).  Two large studies, with sufficient size to control for confounding variables, reported on the risks for women with two previous cesarean deliveries undergoing TOLAC (66, 67).  One study found no increased risk of uterine rupture (0.9% versus 0.7%) in women with one versus multiple prior cesarean deliveries (66), whereas the other noted a risk of uterine rupture that increased from 0.9% to 1.8% in women with one versus two prior cesarean deliveries (67).  Both studies reported some increased risk in morbidity among women with more than one prior cesarean delivery, although the absolute magnitude of the difference in these risks was relatively small (eg, 2.1% versus 3.2% composite major morbidity in one study) (67).

Additionally, the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery.  Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC.  Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited (69).

The power of context and training

This hour long panel discussion followed the screening of More Business of Being Born: The VBAC Dilemma. On the panel are author/midwife Jenny West (The Complete Idiot’s Guide to Natural Childbirth and The Natural Healing Power of the Placenta), author/researcher Henci Goer (The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth), Nekole Shapiro of Embodied Birth, Stephanie Dawn of Sacred Birth and OB/GYN Dr. Craig Klose discussing the merits of vaginal birth after cesarean and various factors that may impede women being able to obtain VBACs.

One thing that stood out to me was Dr. Klose’s comments on VBAC after multiple prior low transverse cesareans (TLC). To sum, he says that he was taught that multiple LTCs were no biggie and he has attended up to VBA5C. This is the power of training and context!

ACOG guidelines, your legal rights, and “forced” cesareans

As attorney Lisa Pratt asserts, “ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.”  You can read in the article, “VBAC bans, exercising your rights, and when to contact an attorney.”

Further, ACOG also says that women cannot be forced to have cesareans even if there is a VBAC ban in place:

Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.  When conflicts arise between patient wishes and health care provider or facility policy or both, careful explanation and, if appropriate, transfer of care to facilities supporting TOLAC should be used rather than coercion.  Because relocation after the onset of labor is generally not appropriate in patients with a prior uterine scar, who are thereby at risk for uterine rupture, transfer of care to facilitate TOLAC, as noted previously, is best effected during the course of antenatal care.  This timing places a responsibility on patients and health care providers to begin relevant conversations early in the course of prenatal care.

Read a summary of ACOG’s VBAC recommendations and the actual original document.  You may also wish to review your options when encountering a VBAC ban and the story of a mom seeking VBA2C who was threatened with a “forced” cesarean when her OB group withdrew support at 38 weeks.

Accreta, previa, hysterectomies, and cesareans

It has been well documented that the risks of placental abnormalities such as placenta accreta, placenta previa, and previa with accreta increase with each cesarean surgery and as a result, so does the rate of hysterectomy.  Silver (2006), a study of over 30,000 women and up to six cesareans quantified these risks per cesarean number.   You can read more about accreta, previa, previa with accreta and their associated complications.

Fang (2006) said, “abnormal adherent placentation [is] the primary indication leading to emergent peripartum [during the last month of pregnancy] hysterectomy… As the number of prior cesareans deliveries rises, the risk of cesarean hysterectomy increases dramatically.”

The Guise 2010 Evidence Report, which was the basis of the 2010 National Institutes of Health VBAC Conference, also discusses the risks of placental abnormalities by the number of prior cesareans.

So if you plan on having more children, a VBAMC (vaginal birth after multiple cesareans) would put a stop to the increasing rates of complications for future births as opposed to another cesarean which would just increase the risks in subsequent pregnancies.

Ultrasound/MRI and previa/accreta

Considering the significantly increasing risk of placenta previa and accreta as the number of prior cesareans increase, the fact that accreta as a 7% maternal mortality rate (due to hemorrhage) and a very high hysterectomy rate (one study found 71%), I do think it’s reasonable, especially if planning an out-of-hospital VBAMC, to have a ultrasound to rule out previa and even an MRI to try to rule out accreta.  (Keep in mind that the 7% & 71% statistics are based on hospital births where women have access to blood products, surgeons, and operating rooms and that if a mom has previa, the likelihood she has accreta rises dramatically.)

While MRI is more accurate for ruling out accreta than ultrasound, though there is no 100% accurate method thus far.

Read more on diagnosing accreta via ultrasounds versus MRI here.  You can also check out ACOG’s committee opinion on diagnostic imaging during pregnancy though accreta and previa are mentioned in passing.

What difference does it make if you know you have accreta before delivery?

Hospitals plan very differently for a delivery when accreta has been diagnosed.  Please go here for more detailed info.

Evidence to suggest previa less likely to “move” in VBAC/VBAMC moms

One large study has found that a previa is less likely to move away from the cervical os if the mother has a history of prior cesareans.  Please go here for more.

Making a plan and moving forward

Your best bet is to review your medical records with several VBAC supportive care providers and get their opinion.  Obtain a copy of your medical records and operative reports from each prior cesarean, get the names of VBAC supportive providers, and ask the right questions.  Read more about planning a VBAC.

VBAC bans, exercising your rights, and when to contact an attorney

legal-gavel-booksA mom recently left this comment and I thought many other women likely have the same question. Keep in mind that this article does discuss America law which may not be applicable to other countries.

________________________________________

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.

_____________________________

Hi Thia!

Many women believe that all one must do to prevent an unwanted cesarean is declare, “I do not consent!” While technically true, you are entitled to control what happens to your body, the reality is, it often doesn’t play out that way. A hospital does not have a legal right to perform a cesarean on you without your consent. However, it still happens either by coercion or lies and even more rarely, by court order.

I think part of the problem is, many women are not familiar with ACOG’s guidelines. As a result, they don’t understand what ACOG recommends and discourages. (For example, many women believe that VBACs should never be induced. That is false.) Women frequently take their OB’s word as the truth. However, ACOG’s recommendations are often obscured by unsupportive care providers to mimic what the care provider wants the mom to think ACOG says. In other words, unsupportive care providers want moms to think that their options are limited per ACOG and that is just not the case.

The fact that you are doing your research gives you a massive advantage over women who just take their OB’s word for it. I highly recommend you review the article I wrote about a mom who was threatened with a forced cesarean after her OB withdrew support of her planned VBA2C at 37 weeks. It includes legal and media contacts. Through the help of the ACLU, ACLU Women’s Rights Project, National Birth Policy Coalition, and National Advocates for Pregnant Women, the mom was granted a trial of labor. I use the (demonized) term TOL because the mom ultimately did have a medically necessary cesarean during labor due to a placental abruption. However, the mom was still happy that she had the opportunity to labor.

That is as much as I can say as a non-attorney. I consulted with the brilliant Lisa Pratt who is an attorney specializing in the legal issues that uniquely affect women during pregnancy and childbirth. She said,

This answer is true for all women, not just this one. If she needs legal advice specific for her situation then she should consult an attorney. You have the right to refuse any treatment you do not want. I am sure that what she is hearing is the same horror stories that we hear of a mom being harassed by the doctor and staff to consent to a c/s or threatening to seek a court order or call CPS. I know this is a scary thought to have to deal with any of these scenarios, but fear of something happening should not keep you from exerting your legal rights, unless you really are okay with what you are consenting to. You cannot assume that the staff is not going to honor your refusal. They are people just like us, some are jerks and some are ethical and will follow your refusal, but you won’t know what you are dealing with until you are in the moment. ACOG guidelines are just that, guidelines, they are not law; while it is nice when they put out a guideline that supports your factual situation, falling outside of their recommendation does not mean you must consent to something you do not want.

You can learn more about Lisa, and schedule a phone consultation if you have further questions, via her website.

Lisa presented at the 2012 VBAC Summit in Miami. Her session, “A Legal Guide to VBAC,” is available for download.

Warmly,

Jen

Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science

PushNews from The Big Push for Midwives Campaign
CONTACT: Katherine Prown, (414) 550-8025, katie@pushformidwives.org
FOR IMMEDIATE RELEASE: August 15, 2011
Study: Two-Thirds of OB-GYN Clinical Guidelines Have No Basis in Science
Majority of ACOG Recommendations for Patient Care Found to Be Based on Opinion and Inconsistent Evidence
WASHINGTON, D.C. (August 15, 2011)—A study published this month in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists, found that barely one-third of the organization’s clinical guidelines for OB/GYN practice meet the Level A standard of “good and consistent scientific evidence.” The authors of the study found instead that the majority of ACOG recommendations for patient care rank at Levels B and C, based on research that relies on “limited or inconsistent evidence” and on “expert opinion,” both of which are known to be inadequate predictors of safety or efficacy.

“The fact that so few of the guidelines that govern routine OB/GYN care in this country are supported by solid scientific evidence—and worse, are far more likely to be based on anecdote and opinion—is a sobering reminder that our maternity care system is in urgent need of reform,” said Katherine Prown, PhD, Campaign Manager of The Big Push for Midwives. “As the authors of the study remind us, guidelines are only as good as the evidence that supports them.”

ACOG Practice Bulletin No. 22 on the management of fetal macrosomia—infants weighing roughly 8 ½ lbs or more at birth—illustrates the possible risks to mothers and babies of relying on unscientific clinical guidelines. The only Level A evidence-based recommendation on the delivery of large-sized babies the Bulletin makes is to caution providers that the methods for detection are imprecise and unreliable. Yet at the same time, the Bulletin makes a Level C opinion-based recommendation that, despite the lack of a reliable diagnosis, women with “suspected” large babies should be offered potentially unnecessary cesarean sections as a precaution, putting mothers at risk of surgical complications and babies at risk of being born too early.

“It’s no wonder that the cesarean rate is going through the roof and women are seeking alternatives to hospital-based OB/GYN care in unprecedented numbers,” said Susan M. Jenkins, Legal Counsel of The Big Push for Midwives. “ACOG’s very own recommendations give its members permission to follow opinion-based practice guidelines that have far more to do with avoiding litigation than with adhering to scientific, evidence-based principles about what’s best for mothers and babies.”

The Big Push for Midwives Campaign represents tens of thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push for Midwives is to educate state and national policymakers and the general public about the reduced costs and improved outcomes associated with out-of-hospital maternity care and to advocate for expanding access to the services of Certified Professional Midwives, who are specially trained to provide it.

Media inquiries: Katherine Prown (414) 550-8025, katie@pushformidwives.org

no

VBAC Ban Rationale is Irrational

Virginia of Hagerstown, Maryland left me this comment in response to the article Why if your hospital “allows” VBAC isn’t enough:

my hospital says that they will do a vbac but they aren’t set up for it because the labor side is far away from the c-section side so if i try to do a vbac and end up having a c section it will take a lot longer to get me to surgery. do you think this is a legitimate reason to consider not having a vbac? im too close to my due date (7 days left) to change hospitals or doctors although i am beginning to wish i would have. ..
-NERVOUS in hagerstown maryland

Hi Virginia,

The short answer is: No, that is not a legitimate reason to deny you a VBAC.

The reality is, you are less likely to experience an uterine rupture than a complication that has absolutely nothing to do with your prior uterine surgery.  (Please read Scare tactics vs. informed consent and scroll down to the chart entitled “Risks far outweigh VBAC” to see for yourself.)

Since obstetrical complications arise during labor in women with no history of uterine surgery that require immediate surgical delivery, or more commonly in women with multiple prior repeat cesareans, how can a hospital claim that they are fit to attend those births, but not yours?

Any birth (VBAC or not) could end in a medically necessary cesarean and any hospital (urban or rural) set up for birth should have a plan detailing how they will respond to those inevitabilities.

I have also often wondered how often women with true obstetrical complications requiring immediate cesareans or even car accident victims requiring surgery, have been unable to receive that care due to otherwise healthy moms and healthy babies undergoing  scheduled elective repeat cesareans occupying the operating rooms?  With 92% of American women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals.

The ability of rural hospitals to safely attend VBACs, as well as a specific plan that they could implement, was extensively discussed at the March 2010 National Institutes of Health VBAC conference.  One doctor spoke during the public comment period and stated that her rural hospital  – without 24/7 anesthesia – had a VBAC rate of over 30%!  It turns out, if a hospital is supportive of VBAC and motivated, they can absolutely offer VBAC safely.  (I also welcome you to read the commentary of two obstetricians and one certified nurse midwife who argued against the VBAC ban instated at their local rural hospital.)

As David J. Birnbach, M.D., M.P.H (2010), who presented on the impact of anesthesiologists on the incidence of VBAC asserted:

Lack of immediate available of anesthesia may not always be a key factor in outcome [during a uterine rupture], especially in cases where the obstetrician is not present. Many cases of uterine rupture can be stabilized while the anesthesiologists becomes available, and examples have been suggested of ways to reduce the risk associated with such a crisis. These include antepartum [prenatal] consultation of VBAC patients with the anesthesia departments, development of cesarean delivery under local anesthesia protocols, finding methods of improving communication on labor and delivery suites, practice “fire-drills,” and development of protocols matching resources to risk.

I urge you to watch Dr. Birnbach’s presentation along with all the presentations from the 2010 NIH VBAC conference.  The American Association of Justice article entitled “When every minute counts,” also discusses improving response times.

These drills would also be helpful to the women who have other obstetrical emergencies including placenta previa, placenta accreta, and other complications that are more common in women with multiple prior cesareans.

Additionally, as I argued here:

Scheduled cesarean section puts anyone else who experiences a medical emergency requiring surgery in danger because those operating rooms become unavailable. I wonder how often women with true obstetrical complications requiring immediate cesareans, such as your wife, or non-obstetrical emergencies such as car accident or gunshot victims, have been unable to receive that urgent, time sensitive care due to otherwise healthy moms and healthy babies undergoing scheduled elective repeat cesareans and tying up the operating rooms? With 92% of women having repeat cesareans (Martin, 2006), I’m sure it’s happened, especially in smaller hospitals, many of which only have one or two operating rooms.  These routine repeat cesareans impact everyone and it’s only going to get worse.

I highly recommend you read the Final Statement produced by the conference as it was the catalyst for the subsequent revision of ACOG’s (2010) VBAC guidelines in the Practice Bulletin No. 115 where they affirmed:

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.

This is a huge change.

The term “immediately available,” first introduced in the 1999 Practice Bulletin No. 5 and then reiterated in the 2004 Practice Bulletin No. 45, was the reason why many hospitals ultimately banned VBAC.  Hopefully the removal of that recommendation in this new Practice Bulletin will result in the reversal of VBAC bans and an overall greater support for VBA1C and VBA2C.  ACOG acknowledged that their prior recommendation was resulting in way to many cesareans and the increasing risks that multiple cesareans bring are significant and unacceptable.  (Please read the risks of multiple cesareans detailed by Silver 2006 in Another VBAC Consult Misinforms.)

The removal of the “immediately available” recommendation is supported by the NIH (2010) Final Statement which found it, if implemented in all hospitals, to be an impossible standard that could result in the closing of many Labor & Delivery units:

Would provision of an anesthesiologist standing by waiting for an emergency at every hospital that practices obstetric care increase patient safety?  In truth, that person would need to be doing nothing else clinically, so even being in the hospital might not qualify for “immediately available.”  Looking at the numbers of anesthesia staff currently available, the minimum requirement to provide immediate anesthesia [per the recommendation of the American Congress of Obstetricians and Gynecologist] care for all deliveries would be to have all deliveries accomplished at facilities with greater than 1,500 deliveries annually.  This would require that approximately three-quarters of all obstetric programs nationwide be closed (Birnbach, 2010).

I am excited and hopeful to see the ripple effects of this new Practice Bulletin especially for women in rural areas.  Hopefully the option of VBAC will become a reality for more women.

______________________________________________

American College of Obstetricians and Gynecologists. (2010, July 21). Ob-Gyns Issue Less Restrictive VBAC Guidelines. Retrieved July 21, 2010, from ACOG: http://www.acog.org/from_home/publications/press_releases/nr07-21-10-1.cfm

Kamel, J. (2010, July 21). ACOG issues less restrictive VBAC guidelines. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/21/acog-issues-less-restrictive-vbac-guidelines/

Birnbach, D. J. (2010). Impact of anesthesiologists on the incidence of vaginal birth after cesarean in the United States: Role of anesthesia availability, productivity, guidelines, and patient saftey. Vaginal birth after cesarean: New Insights. Programs and Abstracts (pp. 85-87). Bethesda: National Institutes of Health.

Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Kirmeyer, S. (2006). Births: Final Data for 2004. National Vital Statistics Reports , 55 (1), 1-102.

National Institutes of Health. (2010, June). Final Statement. Retrieved from NIH Consensus Development Conference on Vaginal Birth After Cesarean: New Insights: http://consensus.nih.gov/2010/vbacstatement.htm

National Institutes of Health. (2010, March 8-10). NIH VBAC Conference: Program & Abstracts. Retrieved from NIH Consensus Development Program: http://consensus.nih.gov/2010/vbacabstracts.htm

ACOG-logo

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.
Photo credit: http://healthmad.com/health/fetal-monitoring/

The Role of Interpretation – ACOG Refines Fetal Heart Rate Monitoring Guidelines

Photo credit: http://healthmad.com/health/fetal-monitoring/

Photo credit: http://healthmad.com/health/fetal-monitoring/

I remember when I was pregnant with my first.  The CNM I hired worked at multiple hospitals, so my husband and I toured each one to get a feel for each hospital’s standard policies and procedures.  A few people I knew questioned why we were bothering doing this since, aren’t all hospitals the same?  While I was expecting some differences, I was really surprised with what I found.

The standard procedures of the three hospitals we toured varied greatly – everything from the use of telemetry (wireless fetal) monitoring to how much bonding time a mom and baby were permitted before baby was whisked away for mandatory hospital procedures to where babies slept at night and whether babies were routinely given sugar water, formula or a pacifier.

I came away realizing how important it is to carefully screen which hospital you chose as well as your OB/midwife and the L&D nurse who will be caring for you during your stay at the hospital.

This June 22, 2009 press release illustrates ACOG’s (The American College of Obstetricians and Gynecologists’) efforts to help standardize the care women receive from OBs.  Specifically, they wish to stabilize the variability in fetal heart rate interpretations which could considerably impact the frequency of the “fetal distress” diagnosis.

EFM refers to external fetal monitoring which most women know as the belt laboring women wear that measures the baby’s heart rate and is connected to a machine which produces a strip of the baby’s heart rate as well as mom’s contractions.

I found these quotes of particular interest (emphasis is mine).

“Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,” says George A. Macones, MD, who headed the development of the ACOG document. “Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”

“Our goal with the ACOG guidelines was to define existing terminology and narrow definitions and categories so that everyone is on the same page,” says Dr. Macones. One of the problems with FHR tracings is the variability in how they’re interpreted by different people. The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.

A meta-analysis study shows that although EFM reduced the risk of neonatal seizures, there is still an unrealistic expectation that a nonreassuring FHR can predict the risk of a baby being born with cerebral palsy. The false-positive rate of EFM for predicting cerebral palsy is greater than 99%. This means that out of 1,000 fetuses with nonreassuring readings, only one or two will actually develop cerebral palsy. The guidelines state that women in labor who have high-risk conditions such as preeclampsia, type 1 diabetes, or suspected fetal growth restriction should be monitored continuously during labor.

Note that VBAC is not listed under “high-risk conditions” that “should be monitored continuously during labor.”  Also, with a 99% false positive rate for cerebral palsy, I wonder about the rate of uterine rupture false positives.

Here is the link, ACOG Refines Fetal Heart Rate Monitoring Guidelines.