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The three biggest concerns with ACOG’s VBAC Guidelines

by Oct 31, 2017Home birth, Hospital birth, VBAC10 comments

Update: In 2019, ACOG released an interim update, 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.

Last week, ACOG released Practice Bulletin No. 184, their latest VBAC guidelines. This document has the potential to greatly influence VBAC access in the United States. These are the words that hospitals and obstetricians point to when they create policy. What ACOG thinks about VBAC has ripple affects throughout the United States, impacting millions of birthing families every year. So, it’s a big deal.

Last week, I shared the eleven things that I love about these guidelines. And with good reason. There’s some excellent new language as well as reiterations of positions that they presented back in 2010. But there are a few places where ACOG misses the mark and these are the three areas that gave me the most concern.

1. The curse of the FTP cesarean

There are several factors that impact dilation and many reasons why someone would receive a cesarean for “failure to progress” aka labor dystocia. So when ACOG said in these latest guidelines, “Similarly, women with a history of cesarean delivery performed because of dystocia have a lower likelihood of VBAC if the current birth weight is greater than that of the index pregnancy with dystocia,” it tweaked me.

It tweaked me because given how inconsistent the diagnosis of labor dystocia is, it’s hard to say that all of the women who had a cesarean for FTP would have similar subsequent labors. Just because someone receives a cesarean for FTP does not mean that they actually met the FTP diagnosis criteria set forth by ACOG. As a result, we cannot honestly lump these women together, measure how their subsequent labors progressed, and then estimate VBAC rates for those who receive an FTP cesarean.

Additionally, it is difficult to accurately predict fetal weight prenatally. So given that the two fundamental concepts of this recommendation come with great variability, the recommendation itself is rather weak.

Yet I know many physicians will read this and just risk out people who had their cesarean for dystocia and are expecting a larger baby. Given the fact that one-third of American birthing people receive their primary cesarean for dystocia means a huge chunk of otherwise good candidates might be told they really aren’t.

And many parents will believe it because they don’t know what ACOG says, they don’t know what the evidence says, and the research has shown time and time again that if an obstetrician prefers a repeat cesarean, that is what the parent will choose.

The bottom line is, while one study ACOG cited did find that women who had a cesarean for FTP have lower VBAC odds if their subsequent baby is expected to be bigger, this still does not help us predict how an individual woman’s labor will play out. And unfortunately, when ACOG makes statements about lower VBAC rates, that can result in whole categories of women being risked out for VBAC… even though that is not what ACOG intends.

2. Just don’t do it at home

It is no surprise that ACOG said that a prior cesarean is a contraindication to home birth. ACOG believes that being pregnant is a contraindication to home birth.

I think a lot of physicians are scared of home birth in general because they don’t know any midwives, are not familiar with their training or scope of practice, have never been present for a home birth, and, for many, their only exposure to home birth are emergency home birth transfers.

So it’s important when forming an opinion – or considering someone else’s opinion – to be clear on what that opinion is based on. While physicians may be an expert in hospital birth, they are not experts in home birth. Additionally, the midwifery model of care is very different than the medical model.

I know physicians who work in collaboration, and even further, strongly support home birth – including home VBAC – because they have taken the time to learn about home birth by creating relationships with home birth midwives.

I believe that if this was commonplace, the benefits would be felt by all, but more importantly, birthing families.

So I’m not holding my breath for ACOG to change their stance on home birth, because I don’t think they ever will. But I do hope that they will acknowledge why pregnant people choose to birth at home and use that information to influence maternity care practices in hospitals.

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    The choice to have a home birth, especially a home VBAC, is not made in a vacuum. It is a direct response to the mistreatment many birthing parents receive in hospitals. It is a reflection of the type of care parents want – individualized midwifery care – and cannot attain at the hospitals in their community. It is a reasonable reaction to the reality that 44% of American hospitals “ban” VBAC and lead their patients to believe that they have no other option than a repeat cesarean.

    Even though ACOG denounces such practices and makes it abundantly clear that hospitals should not be forcing pregnant people to have cesareans per VBAC bans, it still happens. So to attempt to eliminate the only way many parents can achieve a VBAC in the midst of this climate is to discount the huge challenges families face and the very real complications they are seeking to avoid such as placenta accreta.

    I do wish ACOG would expend their energy, influence, and power to reverse VBAC bans and make VBAC as accessible as possible in America rather than trying to further limit VBAC access.

    The good news is, patient autonomy trumps these guidelines. As ACOG said in their own committee opinion on home birth, “Although the American College of Obstetricians and Gynecologists (the College) believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.”

    3. Mentions the VBAC calculator. Three times.

    Where do I start… the VBAC calculator is problematic. It’s problematic because many don’t understand the science behind it, how it really works, what it really tells you, how race impacts its findings, and what you can reasonably do with that information.

    And yet, ACOG mentions the VBAC calculator as a tool three times in the latest guidelines. To create further confusion, ACOG also accurately states, “no prediction model for VBAC has been shown to result in improved patient outcomes.”

    I ask you. What do you think obstetricians will remember? That single statement? Or the three times the VBAC calculator is mentioned as a way “to generate the predicted probability” of VBAC?

    The challenge is, I see more obstetricians using the VBAC calculator to risk out patients entirely rather than using it as a discussion tool. And without parents – and professionals – really understanding the science behind the calculator, and general statistical concepts, they might not be able to interpret the calculator’s findings.

    Where do we go from here?

    ACOG has the power to positively or negatively influence health care policy in America. Given the history of VBAC access, it seems that hospitals are faster to ban VBAC than to loosen restrictive hospital policies. This is why guidelines are not enough to increase VBAC access.

    It’s not enough for the evidence and recommendations to be “out there.” It’s not enough for hospital administrators and providers to read them because some will just pick and choose which recommendations they want to ignore and which to emphasize. While others will interpret the guidelines to justify what they wanted to do anyway (i.e., ban VBAC).

    The only way change can be made is through a coordinated and strategic effort among informed parents and professionals who care about maternal health. And the very first step to creating change is getting your facts down pat.

    So if you want to plan a VBAC, educate your clients, or start a VBAC revolution in your community, download my free report on uterine rupture. It’s the first step to improving VBAC access in your community.

    What do you think?
    Leave a comment.

    What do you think? Leave a comment.

    10 Comments

    1. I find this whole article/website concerning. I had a Uterine Rupture with an attempted VBAC. I have now met many women in my shoes who had the same. It threatened my life, my son’s life, and from many of the women I met through that experience, their children did not survive, or have horrible life-altering complications. Has my opinion on VBAC’s changed, yes. Do I think they should still be available to women, yes. I am a huge believer in my-body/my-choice, but I find this whole website and postings very self-serving. I can tell you that many of us that had UR’s were all pro VBAC, and I am not saying we are no longer pro-VBAC. Some women’s opinion change/some do not. I would say my opinion has altered a bit. I still believe it is a woman’s choice, I also believe there needs to be more discussion of the risks. I am living it, I have met hundreds of other women who are living it, and are just one small support group. I am the statistic, it happens. If you really want to talk VBAC facts, then maybe having a section to those of us who are the statistic would be helpful as well. We don’t serve women unless all the information is out there. To say, “It’s so rare,” and shove the conversation aside does a disservice to all women. Serious complications, sometimes the death of a child, or mother, happens. In order for women to have a well, informed, and complete decision making power over their healthcare, there needs to be more discussion about the the worst case scenarios and outcomes.

      Reply
      • Maureen,

        I am so sorry that you had a uterine rupture. I can’t imagine how frightening that must have been.

        I share your concerns about parents understanding the risks of VBAC. It’s only through learning about the risks and benefits of VBAC and repeat cesarean can parents make an informed decision.

        There are small risks with both VBAC and repeat cesarean that could result in the death of the baby or mother.

        I write extensively about uterine rupture including a series debunking myths as well as the story of a mother who lost her baby.

        With cesarean, the big risk, in my mind, is placental abnormalities like accreta. The risks of accreta after two cesareans is greater than the risk of uterine rupture after one cesarean. 1 in 14 mothers with accreta die as do 1 in 17 babies.

        93% of parents pregnant after a cesarean are never informed of the risks of accreta. They were solely warned about the risks of VBAC, told it was dangerous, and thus scheduled a cesarean never realizing that inadequate informed consent would devastate their family. You can read more about accreta here.

        I agree that parents deserve the truth. And this is it: The risk is small with VBAC and repeat cesarean, but those small numbers represent real parents, real babies, and real heartbreak. And it doesn’t matter how small the statistic is when it happens to you.

        I am so sorry that you were the statistic.

        With much respect,

        Jen

        Reply
      • I just came across this, any chance you still have that replay on FTP Cesareans??? That part of this article described me perfectly. FTP Cesarean, and had GD, so likely will have GD during my next pregnancy, and I want to VBAC!

        Reply
    2. Here in New Zealand we don’t have hospitals banning VBACs but the protocols for management of a VBAC labour, I believe hugely reduce a woman’s chance of vaginal birth after caesarean. I chose to HBAC my babies because, following a c-section for cord prolapse, because I didn’t want routine IV luer insertion, continuous EFHM & routine epidural placement as well as strict monitoring of the duration of labour. I knew the restricted mobility and the interference with the hormonal pathway of labour caused by these restrictions and surveillance would negatively impact the possibility of achieving the vaginal births I was determined to have. In the 30+ years that I’ve been a CBE, even though our understanding of of the hormones that govern labour and birth has increased exponentially, I have seen little change in the lack of confidence, respect and support that the medical establishment worldwide, has for physiological birth.

      Reply
    3. Another great article Jen. The birthing community is lucky to have you. I encourage all women with a nearby VBAC ban to take these new guidelines plus the NIH VBAC Consensus Hearing conclusions to the hospital administration and ask why there is still a VBAC ban in place?

      Reply
    4. Regarding #2, if in-hospital care providers consistently gave evidence-based care and true support to VBAC moms, we might not choose HBAC. After 2 hospital VBA2Cs I knew I couldn’t handle the stress of that again and had our 5th baby at home. I had a wonderful homebirth experience and think it’s a great option for many women, but I hated that I chose it because I had so few options. Because the closest hospital has a VBAC ban. Because the midwifery group I would’ve chosen couldn’t take me onsince I’ve had 2 c-sections. (Even though I’ve had TWO vaginal births since then and one of them was over 10 pounds!) Because the 2 OBs who reliably support VBAMC are an hour away from me and regularly induce at 40 weeks. Because the on-call doctors and nursing staff at those hospitals are not VBAC friendly and I’d have to contend with them my whole labor.

      Reply
    5. BRAVO! Jen. Wonderful insights as usual. Thank you for all that you do!!!

      Reply
    6. I had my first baby by csection due to failure to progress (conned into induction because 41wks) in a hospital. If I listened to ACOG in a vacuum I wouldn’t have had my wonderful HBAC because my first OB said she would only support me in a TOL for a VBAC if my baby was 6lbs or less and I would go into labor at/before 40 wks! Luckily I knew better and found a supportive and knowlegeable midwife! My second boy was born exactly the same size as my first, 8lbs 8oz and 21 inches!! Sad part is she is known to be VBAC supportive in my region… think of how many people she turned away or said a RCS was necessary because they didn’t fit her criteria and they didn’t know better!

      Reply
    7. Totally agree with everything you said here, Jen. All of the hospitals banning VBACs will not change…. are you kidding? They have been luxuriating in scheduled operations… more $$, more sleep and control of their schedules for the docs… I just don’t see the reversal happening unless ACOG addresses this specifically… it seems like their guideline changes happen in baby steps…. sigh…
      keep up the good work! I’m a 30 yr midwife and home vbacer myself.. still trying to make a difference!

      Reply

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    Jen Kamel

    As a nationally recognized consumer advocate and Founder of VBAC Facts®, Jen helps perinatal professionals, and cesarean parents, achieve clarity on vaginal birth after cesarean (VBAC) through her educational courses for parents, online membership for professionals, continuing education trainings, and consulting services. She speaks at conferences across the country, presents Grand Rounds at hospitals, advises advocates seeking legislative change in their state, and serves as a expert witness in legal proceedings. She envisions a time when every pregnant person seeking VBAC has access to unbiased information, respectful providers, and community support, so they can plan the birth of their choosing in the setting they desire.

    Learn more >

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