Last week, I shared the eleven things that I love about ACOG’s latest VBAC 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.
When I found out that ACOG released their new guidelines yesterday, I couldn’t wait to devour them. This morning, I had an opportunity to cuddle up with the new recommendations and I’m quite pleased. As always, there are things to like and areas where I think ACOG missed the mark. But here are the eleven good things about ACOG’s 2017 VBAC guidelines.
Recently, I had a great extended conversation on racism in birth work at a VBAC Facts training for professionals in Covington, LA. And I wanted to share it with you. One doula shared that we simply needed to treat all clients the same regardless of race. What she was saying is that we should be colorblind. Now, I felt the good intentions in her heart. I knew what she was trying to say. Because there was a time that I believed the same thing. I was so glad she spoke up because it kicked off a tough conversation that needed to be had.
So what matters more: Our personal experience? Or the conclusions of medical evidence? I suspect that most of my readers would say, the evidence. Hands down. And that is what most people believe… until they experience a bad outcome. That’s when things become more complicated. That single event can override all their knowledge. Everything they believed to be true. Suddenly all those statistics from the research come flying off the page. They are no longer just a number. They are now associated with a face… a baby… a parent.
I have thought about AB 1306 for so many hours since I initially opposed it last Friday and I’m feeling really conflicted about it. Let me share with you why. Removing physician supervision will improve the ability of CNMs to practice autonomously including offering VBAC in the hospital setting (where hospital policy permits) and in birth centers (provided the CNM opts to offer VBAC). This could be a good thing for VBAC families and a great thing for all the other people CNMs serve. And so it’s really tough because it could negatively impact the small number of women who plan home VBACs by requiring them to have a VBAC consult with an OB. So, what is the right decision?
A woman who had four cesareans, after planning VBACs and home births, recently contacted me. She didn’t know where she fit into the birth community. My heart went out to her because there have been periods in my life when I have felt isolated and alone. And it’s a crappy feeling. I replied to her, “A vaginal delivery is not required to participate in the birth community. There are many cesarean moms just like you who are seeking compassion, connection, and understanding. You could be a soft place for other women to land as they mourn (or celebrate!) their cesarean deliveries.”
Women who have had uterine ruptures and lost their babies have endured some of our greatest fears. But they are part of our community as well. When the VBAC Facts Community, a Facebook group, was opened to the public, we welcomed and embraced the parents who joined us after their loss. Often they felt like they were no longer part of the birth community. They didn’t know where they fit in. They felt isolated and yet they wanted to share their story. We had many loss moms as members and many parents who were planning VBACs who wanted to hear their stories.
I’m in an online group for labor & delivery nurses where the discussion of vaginal birth after cesarean (VBAC) at home came up. While some understood the massive VBAC barriers many women face, others simply said, “Find a hospital that supports VBAC.” I left a late-night comment stating that “finding another hospital that supports VBAC” is just not a reality in many areas of the country. It’s literally not possible. Not even in the highly populated state of California. I also suggested rather than calling women stupid or debating the validity of the decision to have a home VBAC , we should consider why women make this decision.
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.
“No one can force you to have a cesarean.” I see this all the time in message boards. That’s just not true. Let’s start with what is ethical and legal: Yes, no one can legally force you to have a cesarean. ACOG even says in their latest VBAC guidelines that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.” So even if your facility has a VBAC ban, they still cannot force you to have surgery… legally or ethically. But then you have reality: It happens all the time, but it may look different than you expect.
Internal bleeding from uterine rupture can cause referred pain through the phrenic nerve which can present in the shoulder. Shoulder pain is sometimes not included in lists of uterine rupture symptoms, but I have seen it cited multiple places (see below) and have had conversations with OBs, nurses, and anesthesiologists who have experienced uterine ruptures with shoulder pain. I’m also aware of two cases where the uterine rupture diagnosis was delayed because staff was not familiar with the incidence of referred pain.
A reader recently asked, “I wonder however if there are studies that compare the method of induction. My Doula said that the increase rates of uterine/ scar rupture was due to using high dosages of Pitocin, but now the induction uses lower dosages and administered at longer intervals. Do you know something about this?”