Correction: I initially said that ACOG has never required a prior vaginal delivery to be a VBA2C candidate. Thank you to a reader who brought ACOG’s 2004 VBAC guidelines to my attention where they did include this stipulation.

Update: In 2019, ACOG released their latest VBAC guidelines, Practice Bulletin No. 205. The only significant change was their recommendation regarding the timing of elective repeat cesarean sections among those who have had an uterine rupture.

Have you heard that ACOG doesn’t support VBAC? Or that they don’t “allow” VBAC in specific circumstances? Let’s read what ACOG actually says and bust some myths. Turns out, much of what people say and believe about ACOG’s VBAC guidelines is untrue.

As always, there are things to like and areas where I think ACOG missed the mark. But here are the top eleven highlights from the latest VBAC guidelines, Practice Bulletin No. 184.

1. Who is a VBAC candidate?

ACOG reaffirms their 2010 recommendations about VBAC candidacy word-for-word:

“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 and offered TOLAC [trial of labor after cesarean].”

In terms of who is “generally” not a candidate, ACOG uses the same language while acknowledging, again, that “individual circumstances must be considered in all cases.”

I also liked this statement which I hope will result in more conversations about risk levels and individual preferences:

“Global mandates for TOLAC are inappropriate because individual risk factors are not considered.”

This is an important concept because VBAC candidacy is not just a checklist, but rather a discussion of many variables.

ACOG does outline conditions or histories that are associated with lower VBAC rates. But providers and birthing people need to couple that with our inability to predict the future and the multiple factors that can impact outcomes.

Further, ACOG is crystal clear about who makes the ultimate final decision about mode of delivery by repeating this statement from the 2010 guidelines:

“After counseling, the ultimate decision to undergo TOLAC or repeat cesarean delivery should be made by the patient in consultation with her obstetrician or other obstetric care provider.”

The provider advises. The patient decides.

2. Individualized risk assessment

ACOG reaffirms that “the balance of risks and benefits appropriate for one patient may be unacceptable for another.”

This is why it’s so important for parents – and professionals – to truly understand the risks and benefits of VBAC and repeat cesarean. It’s only through knowing the truth about VBAC can parents make an informed decision about what is the right decision for them.

They also state,

“The decision to attempt TOLAC is a preference-sensitive decision, eliciting patient values and preferences is a key element of counseling.”

Sometimes providers can project what they would choose for themselves onto birthing people. But it’s important to honor the decisions of birthing people even if they are different than the provider’s recommendation. This is one of the fundamental concepts of patient autonomy. Inform. Recommend. Support.

3. Considering individual circumstances

There’s a bit of discussion over what does and does not risk someone out for a VBAC. This isn’t new.

But what is new is ACOG’s attention on the importance of considering individual circumstances,

“However, the likelihood of achieving a VBAC for an individual varies based on her demographic and obstetric characteristics.”

Population statistics help us get a quick snapshot of the overall odds among people with similar histories or conditions. But it doesn’t help us predict how an individual labor will play out.

When caring for an individual, and guiding them through the decision making process, it’s important to acknowledge the many variables at play in their specific situation.

4. Future risks of cesareans

I love that ACOG mentions placenta accreta, when the placenta abnormally attaches to or through the uterine wall, upfront in the first paragraph under clinical recommendations.

They stress the “dose-response” relationship between cesareans and accreta, meaning, that the risk of accreta increases with the number of prior cesareans, and highlights that “decisions regarding TOLAC should consider the possibility of future pregnancies.”

I would double underline that, since 49% of American pregnancies are unplanned per the CDC.

Hopefully this language will prompt providers to include discussions of placenta accreta with their clients, especially those who are planning more children.

5. Our inability to predict VBAC

While reviewing odds of predicted VBAC success, I appreciate that ACOG spelled out:

“However, a predicted success rate of less than 70% is not a contraindication to TOLAC.”

This is especially important to stress since they reference using a VBAC calculator several times throughout the guidelines.

VBAC calculators tend to underpredict VBAC odds, especially for Black and Latinx folx, so that’s one of the three topics that gave me the most concern.

6. Vaginal birth after more than one cesarean

ACOG reaffirms their 2010 stance on vaginal birth after two cesareans (VBA2C) when they say 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.”

No mention of a prior vaginal delivery required to be a VBA2C candidate even thought that is what some OBs tell women. This is why it’s important to read the latest guidelines. While ACOG did say in 2004 that only those with a prior vaginal delivery were candidates for VBA2C, that recommendation was nixed from the 2010 guidelines.

Additionally, many people claim that ACOG does not “allow” VBAC after three or more cesareans. But here is what ACOG actually says:

“Data regarding the risk for women attempting TOLAC [trial of labor after cesarean] with more than two previous cesarean deliveries are limited.”

Nowhere do they say VBAC after three or more cesareans is not recommended. This is certainly an area of unknown risk, but still, patient autonomy should be the driver of all medical decisions.

7. What isn’t a VBAC contraindication

ACOG reaffirms their recommendations from 2010 when they say suspecting a big baby, going beyond 40 weeks, having a short birth interval, having a low vertical or unknown scar, expecting twins or having a high BMI are not reasons to risk out planned VBAC.

They also reaffirmed that induction, augmentation, epidural, and external cephalic version remain options during planned VBAC.

8. What facilities should offer VBAC

This was the most exciting part. It is clear to me that ACOG is trying to expand VBAC access in hospitals when they say:

“Available data confirm that TOLAC may be safely attempted in both university and community hospitals and in facilities with or without residency programs.”

They also reaffirmed what they said in their 2010 guidelines:

“Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries.”

But in 2017, they added more detail:

“…women attempting TOLAC should be cared for in a level I center (ie, one that can provide basic care) or higher. Level I facilities must have the ability to begin emergency cesarean delivery within a time interval that best considers maternal and fetal risks and benefits with the provision of emergency care.”

When I read this, I hear, “If you offer labor & delivery, you should be offering VBAC. Because if you aren’t prepared for that first time mother who has a cord prolapse, you aren’t prepared for birth.”

9. “Immediately available” and coercion

Immediately available, and the idea that it means 24/7 anesthesia coverage, has been a sticking point in the past relative to VBAC access.

In these guidelines, ACOG reaffirmed their 2010 stance on “immediately available” which reflected the reality of American obstetrics: There are simply not enough anesthesiologists in America to provide 24/7 coverage for all labor and delivery units. So while “immediately available” may be ideal for all hospitals and all birthing people, it is not a requirement for offering VBAC.

They also repeat that restricting access is not the intention of the “immediately available” recommendation.

In other words, hospitals banning VBAC and coercing parents into repeat cesareans was not ACOG’s intention. Yet that is exactly what has happened across the United States due to how past guidelines have been interpreted.

10. What to do if “immediately available” isn’t available

Just as they did in their 2010 guidelines, ACOG stressed an honest discussion of available resources and respect for patient autonomy in the absence of “immediately available.”

They also reaffirmed that while transfer of care to a larger facility may be an option in some communities, it is not always.

They reiterated that patients should be “allowed to accept increased levels of risk” while being informed on the risks and benefits of their options and available alternatives.

11. VBAC bans and “requiring” repeat cesareans

This excellent statement is again revived from the 2010 guidelines because it’s so important,

“Respect for patient autonomy also dictates that even if a center does not offer TOLAC, such a policy cannot be used to force women to have a cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery.”

While ACOG stated in 2010, “…transfer of care to facilities supporting TOLAC should be used rather than coercion,” in 2017, ACOG sums it up in four words, “Coercion is not acceptable.”

This is a wonderful step in the right direction, but I urge ACOG to use even stronger language regarding VBAC bans because while forced cesareans illegal and unethical, it still happens.

I would love to see language like this in ACOG’s guidelines:

“VBAC bans violate ethical guidelines and patient autonomy. The expectation that parents should exchange the increased risks that come with cesarean surgery, including deadly placental abnormalities, to reduce the perceive legal liability of their provider, is unreasonable. ACOG denounces such policies and urges hospitals with labor & delivery units to rescind their bans and serve the cesarean families in their community with dignity and respect. Continuing education of health care providers might be needed to ensure that all are knowledgeable on the true medical evidence of VBAC and outdated beliefs and policies have been eliminated.”

I can dream, right?

Will these new guidelines increase VBAC access?

There is a lot to love in the latest guidelines. As always, how they are implemented depends on a lot of factors.

But the truth is, and we’ve seen this time and time again, ACOG can say great things and it makes very little difference in terms of hospital policies and individual provider preferences.

Do you know what makes the greatest impact? Informed parents teaming up with advocates and professionals in their area to create change.

So, we need to get the truth about VBAC into the hands of parents, and the professionals who care for them. It’s only through achieving clarity on the evidence and politics of VBAC can we work together to improve access.

If you are a professional who wants to learn more about the VBAC evidence so you can give your clients the best support and increase VBAC access in your community, join the VBAC Facts® Membership for Professionals.

If you are a parent who wants to plan your victorious VBAC, the first step is to learn the facts. The most comprehensive and accurate resource available is “The Truth About VBAC™ for Families.”