Update November 29, 2017: Since this article was published, ACOG released even stronger guidelines specifying that any Level 1 hospital could offer VBAC: “Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries…women attempting TOLAC should be cared for in a level 1 center (ie, one that can provide basic care) or higher.” (ACOG, 2017)
If ACOG ever intended for 24/7 anesthesia or OB presence to be required to offer VBAC, they would have used plain, clear, and unambiguous language to express that, not vague phrases like “immediately available” which are open to interpretation. This article has been updated with these new recommendations.
Update September 13, 2021: It’s been four years since ACOG asserted that level 1 hospitals can offer VBAC and two years since they reiterated this sentiment in their 2019 interim guidelines. Yet we still have hospitals in the United States who "require" repeat cesareans via VBAC bans while citing ACOG and “patient safety.”
In 2010, I sat next to an OB/GYN during a lunch break at the National Institutes of Health VBAC Conference. She told me about how she worked at a rural hospital, without 24/7 anesthesia, that offered planned 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, whether the woman laboring has a prior cesarean or not.
What a hospital needs to offer VBAC
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 are associated with higher rates of a variety of complications in the current and future pregnancy like placenta accreta spectrum as well as cesarean hysterectomy and excessive bleeding. Further, each prior cesarean increases the risk of life threatening bowel obstructions from post-surgical adhesions decades later.
Additionally, rural hospitals do not have the appropriate staffing or resources to adequately manage an accreta because its response requires more than (local) anesthesia and a surgeon.
As labor and delivery nurse Naomi Shim shared, "Frankly as an L&D nurse I've seen a hell of a lot more terrifying hemorrhages from placenta accreta than uterine rupture. And there's more accreta than uterine rupture."
There will aways be a percentage of accretas that are missed prenatally. As more primary and repeat cesareans occur in rural communities, the incidence of accreta will increase. And we will see an increase of maternal mortalities in these communities. This is a reality and numbers game. (Read more on how morbidity, mortality, and ideal response differs between uterine rupture and accreta.) We have to remember this as we have conversations about safety, staffing, and informed consent.
What ACOG says about "immediately available"
When I hear hospitals of any size pointing to ACOG's 24/7 anesthesia "requirement" as the reasoning behind their VBAC ban, I think of that OB/GYN and ACOG's 2010 guidelines which instructed:
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.
Since then, ACOG's 2017 VBAC guidelines introduced this language:
Trial of labor after previous cesarean delivery should be attempted at facilities capable of performing emergency deliveries…women attempting TOLAC should be cared for in a level 1 center (ie, one that can provide basic care) or higher.
ACOG affirms that it is possible and reasonable to offer VBAC without 24/7 anesthesia. Not only that, rural hospitals offer VBAC because of the real risks that accompany cesarean birth.
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Uterine rupture, facility resources, and choice
It would be ideal if every hospital had 24/7 anesthesia. But they don't and that is not a realistic expectation. Managing a uterine rupture in a low-resource setting is not the ideal scenario. But neither is attending a surprise accreta in a rural community, performing a cesarean hysterectomy, or responding to a severe postpartum hemorrhage - all of which are complications associated with repeat cesarean.
It's also not ideal to have VBAC bans mandating repeat cesareans that expose women to the increasing risks of surgical birth as a matter of policy—risks, like placenta accreta, that can be far more serious and life-threatening than the risks of VBAC. Or for someone to drive hours in labor because no hospital in their community supports VBAC. Or to have state troopers attending roadside births. None of these scenarios are ideal.
Frank conversations about staffing and resources should be part of the informed consent conversation and women have the right to make their own medical decisions. As ACOG affirms in their VBAC guidelines,
Consistent with the principle of respect for patient autonomy, patients should be allowed to accept increased levels of risk... After counseling, the ultimate decision to undergo TOLAC or a 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.
ACOG reiterates this sentiment in their committee opinion on informed refusal,
a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected... The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge.
Women get to choose whether they accept that incremental increase risk that could be present during a labor after cesarean in a community hospital or travel to the next closest tertiary level facility who supports VBAC.
When community hospitals maintain VBAC bans, that violates patient autonomy, prohibits informed decision making, and increases the incidence of cesarean-related complications like placenta accreta spectrum which harms public health and erodes public trust in the health care system.
We get to come up with better options
We can’t continue to pretend that hospital VBAC bans serve public health because they increase the risks of more serious complications in future pregnancies as well as hold lifelong implications for the mother.
Learning how to perform a cesarean under local anesthetic makes hospitals—regardless of geography—safer places to give birth. It enables them to perform stat cesareans when anesthesia is unavailable. This coupled with strategies that hospitals can employ to improve outcomes, such as fire drills, means better outcomes for all.
As ACOG states in their VBAC guidelines,
"In settings where the resources needed for emergency delivery are not immediately available, the process for gathering needed staff when emergencies arise should be clear, and all centers should have a plan for managing uterine rupture."
This perspective and approach not only honors patient autonomy, but could improve outcomes for everyone at that facility regardless of how they birth.
How to reduce maternal deaths
If you would like to learn more about how to reduce the incidence of maternal mortality, as well as "near misses," at your facility, join VBAC Facts® Professional Membership and attend our continuing education training “Decoding Maternal Deaths: Why Birthing People Die and How We Can Turn the Tide.”
In this continuing education training approved for 2.6 nursing contact hours through the California Board of Registered Nursing, you will learn how often these deaths are preventable, how racism, high BMI, and neighborhood impacts risk, and actional steps so you can reduce maternal deaths, one person at a time. Join membership today and take the first step towards better health care outcomes.
Jen
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About Jen Kamel
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Jen Kamel is the CEO and Founder of VBAC Facts® Since 2007, her focus has been to provide objective, accurate information about the data available on VBAC and repeat cesarean to parents, professionals, policymakers, and the court so all decisions can be informed, ethical, and just. VBAC Facts® works to achieve this mission through their educational courses for parents, online membership for professionals, continuing education trainings, and consulting services.
As an internationally recognized consumer advocate, Jen speaks at conferences across the world, presents Grand Rounds at hospitals, advises on midwifery laws and rules that limit VBAC access, educates legislators and policy makers, and serves as an expert witness and consultant in legal proceedings.
VBAC Facts® 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.
What do you think?
Leave a comment.
So, yes, it is possible and reasonable to offer VBAC without 24/7 anesthesia.
Our hospital will not allow VBAC or VBA2C. Which is horrible because I would like to have one. And many other moms would too in this area. It’s 2 hours away to have one at a bigger hospital. Even tho a hospital an hour away states they are VBAC friendly. We have not heard of one that hasn’t become Cesarean.
Island hospital Anacortes WA
The hospital for which I ((we have decided to birth our 2nd baby into this world)) does in fact, permit and offer VBAC’s based on the state of health of the mother during her 1st/most recent birth ((C-section)).
In my case, because it is a totally separate hospital that is in the inner, more urban part of the city ((and is the county hospital)) my husband still wishes for us to birth this baby at the same hospital as our 1st baby, plus we concluded, in the case that we enter into the laboring process, we do not believe it to be in our best interest to drive all the way across Dallas to the hospital of our choosing this time around, as opposed to driving less than 10 minutes around the corner to the same hospital that delivered our 1st baby!
I hope my post is clearly typed. If not, than please comment and ask me questions.
None of the hospitals in Southern OHio “offer” VBACs, only the larger teaching hospitals up in Columbus, 2 hrs away. However, I have had several clients who have managed to get VBAC births in these rural hospitals that say they don’t do them.
I think the practitioners have a huge influence. In El Paso, TX, all the major hospitals say they support VBAC & VBAC2, but very few of the practitioners support VBACs and therefore they will coerce/force you into a repeat c-section. If practitioners and nursing staff support VBACs, they will find a way for their patients to have access to them.
I’m very upset by the tone of this article. I’m a labor n delivery nurse and pro VBAC. I can tell you that a c section done under a local anesthetic is barbaric and only done under emergency conditions. I’ve worked in these tiny hospitals, it’s not a place to have an emergency during your delivery. Not only does a mother scream in pain during a c section done under a local, but is there someone qualified to take care of a baby that may need some advanced support once it’s born? PROBABLY NOT, does the blood bank carry more than 2 units of blood that it has to share with the ER? PROBABLY NOT. Is there an ICU that can care for the mother and or baby after this emergency? NO, for sure no. This article advocates a dangerous situation and everyone who is trying to “get my VBAC” is not seeing the whole picture either. If you have been in the OR and listened to a mother scream in pain while her baby is cut out, and then the baby is given to an inadequate team while they wait for a transport NICU team?? If you have witnessed this??? You would stop and think a minute about what you are demanding or manipulating to get your way. People aren’t trying to prevent you from your dream delivery…..because they have seen what can happen, they are tryng fo protect you and your baby. This stop and think about the big picture tor Gods sake!
I’m not advocating for cesareans under local anesthesia. They are not ideal.
It would be ideal if each hospital that offered L&D had 24/7 anesthesia.
But that’s not possible.
So given our imperfect system, and the increasing risk of mortality and morbidity associated with accreta, how do we move forward?
Do we ban VBACs and require repeat cesareans? And ignore patient autonomy while exposing them to the increasing risks of higher order cesareans as well as the increasing risk of developing accreta in future pregnancies?
Or do we offer parents a choice? Drive to the closest tertiary level hospital or plan for a VBAC at a community hospital?
That’s what this article is about. It’s looking at the bigger picture and examining issues like VBAC bans, patient autonomy, and the public health.
Who should ultimately make these decisions? What’s at stake?
I argue that the pregnant person is the one who should make this call.
And there are community hospitals without 24/7 anesthesia who honor patient autonomy and offer VBAC.
Curious, would there be much difference between an emergency between a VBAC delivery and a non-VBAC delivery at this hospital? If anesthesia is the difference for VBAC allowed at a hospital, then people should be arguing that this hospital shouldn’t even be delivering babies at all. Just thinking out loud.
Absolutely, one could make that argument and many have. The challenge is that maternity care deserts are real. These are huge areas of the country where people have to drive long distances in order to access maternity care. As a result, we see worse outcomes among birthing parents living in rural areas. Rural hospitals play a critical role in making maternity care accessible in those underserved communities. Thus, even without 24/7 anesthesia coverage, rural hospitals do attend births and have emergency protocols in place. There are motivated rural hospitals – in the US and Canada – that safely offer VBAC by prioritizing the medical evidence and patient autonomy. This is consistent with ACOG’s clarification introduced in their 2017 VBAC guidelines where they clearly state that all Level 1 hospitals can offer VBAC. I delve deeper into the guidelines and politics of VBAC access in “The Truth About VBAC™ for Professionals,” one of the many continuing education trainings available within VBAC Facts® Professional Membership. If you are interested in learning more about this topic, that is the best place to go.
What about rural hospitals that do not have OB in house? At our hospital, an ER can provide emergency anesthesia if needed but we do not have OB in house. Our nurses are scared and irate that our providers are encouraging patients to Vbac but them requiring them to sign off all liability. What are your thoughts?
Hi Karly, This is a complex question that cannot adequately be addressed in a quick comment. In short, there are rural hospitals that do not have OB in house, but nevertheless support VBAC. These hospitals support VBAC because they value patient autonomy, honor when parents want to birth in their community rather than traveling to larger hospitals, and acknowledge the risks associated with multiple cesarean sections. I believe that further education about VBAC, and specifically VBAC within rural hospitals, would help mitigate the fears of your colleagues. We discuss the research, considerations, and ethics of VBAC at large, and specifically in rural facilities, within VBAC Facts® professional membership. You can learn more at https://vbacfacts.com/membership.