In 2010, I was sitting next to an OB/GYN during a lunch break at the National Institutes of Health VBAC Conference. She was telling me about how she had worked at a rural hospital, without 24/7 anesthesia, that offered vaginal birth after cesarean (VBAC).
I asked her what they did in the event of an emergency. “I perform an emergency cesarean under local anesthetic,” she plainly stated. She explained how you inject the anesthetic along the intended incision line, cut and then inject the next layer and cut, all the way down until you get to the baby.
It certainly wasn’t ideal, but it was how her small facility was able to support VBAC while responding to those uncommon, but inevitable, complications that require immediate surgical delivery.
They had everything a hospital needs to offer VBAC: a supportive policy, supportive providers, and motivation to make VBAC available at their hospital.
From a public health standpoint, it’s to our benefit to offer VBAC because repeat cesareans increase the rate of accreta in future pregnancies as well as hysterectomy and excessive bleeding.
And rural hospitals are NOT capable of managing an accreta because it requires far more than (local) anesthesia and a surgeon. (Read more on how morbidity, mortality, and ideal response differs between uterine rupture & accreta.)
When I hear of smaller, rural hospitals telling women that they can’t offer VBAC because “ACOG requires” 24/7 anesthesia, I think of that OB/GYN and ACOG’s (2010) guidelines which state
Women and their physicians may still make a plan for a TOLAC [trial of labor after cesarean] 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.
So, yes, it is possible and reasonable to offer VBAC without 24/7 anesthesia.
It is ideal? No.
But do you know what else is not ideal?
It’s not ideal to have VBAC bans mandating repeat cesareans that expose women to the increasing risks of surgical birth across the board as a matter of policy—risks that can be far more serious and life-threatening than the risks of VBAC.
It’s not ideal to have any vaginal delivery at a hospital that doesn’t offer 24/7 anesthesia, because any woman giving birth may require emergency surgery.
It’s not ideal to have a cesarean (scheduled or emergency) at a hospital that doesn’t have a blood bank.
It’s not ideal nor realistic to have every pregnant woman drive hours in labor to larger hospitals that offer blood banks, 24/7 anesthesia, and various obstetric sub-specialties for planned VBAC.
It’s not ideal to have state troopers attending roadside births for some of those women.
And it’s deadly for rural hospitals to be managing a surprise accreta.
So, we have to come up with better options.
We can’t continue to pretend that banning VBAC is in the best interest of families. It does not serve our communities in the long run because it simply exposes the ones we love to a more serious complication in future pregnancies.
Learning how to perform a cesarean under local anesthetic makes hospitals—regardless of geography—safer places to give birth. It enables them to perform cesareans more quickly when they don’t have an anesthesiologist in the hospital but the baby needs to be born NOW.
This could make a huge difference in the outcomes for any laboring mom—VBAC or non-VBAC—as well as her baby.
Learn more about VBAC barriers and watch me debunk the four reasons why hospitals ban VBAC in my workshop, “The Truth About VBAC.”
Does your rural hospital offer VBAC or not?
Does your urban or suburban hospital offer VBAC or not?
Leave a comment below!
American College of Obstetricians and Gynecologists. (2010). Practice Bulletin No. 115: Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology, 116 (2), 450-463,http://m.acog.org/Resources_And_Publications/Practice_Bulletins/Committee_on_Practice_Bulletins_Obstetrics/Vaginal_Birth_After_Previous_Cesarean_Delivery
Kamel, J. (2015, April 2). Too Bad We Can’t Just “Ban” Accreta – The Downstream Consequences of VBAC Bans. Retrieved from Science & Sensibility: http://www.scienceandsensibility.org/placenta-accreta-vbac-ban/
Kamel, J. (2010, July 22). VBAC ban rationale is irrational. Retrieved from VBAC Facts: http://vbacfacts.com/2010/07/22/vbac-ban-rationale-is-irrational/
Komorowski, J. (2010, Oct 11). A Woman’s Guide to VBAC: Putting Uterine Rupture into Perspective. Retrieved from Giving Birth with Confidence: http://www.givingbirthwithconfidence.org/p/bl/ar/blogaid=181