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Wednesday
Jul212010

Did ACOG (finally!) Take Their Meds?

If you haven’t already heard the screaming in the streets, let me be one of the first (thousand!) to let you know that this afternoon, the American Congress of Obstetricians & Gynecologists released guidelines that aim to lower the repeat cesarean rate as well as saying that women having a VBAC after 2 cesareans or who are carrying twins or women with an undocumented previous incision ALL should be permitted/encouraged to TOLAC (trial of labor after cesarean).

In keeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, ‘The College [sic] guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC,’ said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago. “ (emphasis mine)

Am I dreaming?! Could ACOG have actually said something that aligns itself with facts? Beyond stunning.

Also, “Approximately 60-80% of appropriate candidates who attempt VBAC will be successful. (!!!!!!!!!) A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy, bowel and bladder injury, transfusion, infection, and abnormal placenta conditions (placenta previa and placenta accreta).”

When the old guidelines were put into place in 2004, a monumental shift occurred that forced hundreds of thousands of women to endure, by force even, a repeat cesarean. The two criteria quoted here, whipped the insurance and hospital admin industry into an apoplectic frenzy.

“…a physician (must be) immediately available throughout active labor who is capable of monitoring labor and performing an emergency cesarean delivery; and the availability of anesthesia and personnel for emergency cesarean delivery.”

Because of these few words, an entire mindshift occurred regarding VBACs and the last six years have been HELL for far too many women.

In March 2010, the National Institutes of Health had a symposium to explore the VBAC “problem” and to try and find solutions. For two-and-a-half days, expert after expert, from OBs to mothers, shared data… scientific data… proving the appropriateness of offering VBAC. I wrote a post, What I Learned Watching the NIH Conference, if you’re interested in reading another perspective of the symposium. I know I am not alone in thinking the words of that conference were inside soap bubbles and would drift away and pop over the ocean somewhere, drowning out any of the positive ideas that were presented.

But, apparently, somebody was listening!

ACOG says, “Women and their physicians may still make a plan for a TOLAC 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. ‘It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance,’ said Dr. Grobman. And those hospitals that lack ‘immediately available’ staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place for managing emergency uterine ruptures, however rarely they may occur, Dr. Grobman added." 

One of the most heinous aspects of the VBAC Wars has been when women have been forced, by law and/or physical force to have a repeat cesarean. Women have been cut open even as they screamed “I refuse consent!” One of my own clients had a baby at +2 station, shoved back up so she “could” have a cesarean. I tell the story in “Forced Cesarean.” I still get sick to my stomach remembering the experience; nothing like what the mom feels, I’m sure. Addressing this issue, ACOG says:

“The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center.”

Or a MIDWIFE. I’ll take her.

Even as the print was barely dry, commentaries around the Net had begun. The International Cesarean Awareness Network (ICAN) says:

However, more than a revision of the VBAC Practice Bulletin is required to reverse the over a decade long trend of increasing cesarean rates and decreasing VBAC rates.  ICAN challenges ACOG to take an active role in educating both women and practitioners about healthy childbirth practices; practices that not only encourage VBAC but discourage the overuse of primary cesareans.” 

The LA Times says:

“The National Institutes of Health report combined with ACOG's new guidelines have the potential to usher in a new era of childbirth in the United States, returning it to a more natural, less-invasive event. Women's health experts nationwide have long agreed that one-third of all births by surgery is unnecessarily high. But, no matter what the medical evidence says, whether the attitudes of doctors and women will change to favor a less-invasive and medicalized — as well as slower and less convenient — approach to childbirth remains to be seen.

I know many more commentaries will be born in the next couple of days.

I am absolutely shocked to read the new guidelines. I know many women don’t believe one word ACOG says, but I can’t help but pray/dream that this statement might actually cause a seismic shift in maternity care.

I’m crossing my fingers, but not holding my breath.

 

A mama after her successful VBAC.

 

 

 

 

 

 

Reader Comments (16)

Wow, this is great news. With my 3 kids, I had a c-section, VBAC, and then another c-section. I was pregnant for a tiny amount of time last fall before having a miscarriage and during those days I started trying to find a doc who would be ok with VBA2C... I just couldn't imagine planning another c-section, even though right after my 3rd baby's birth I thought that I might have scheduled a c/s if I ever had another baby. I hope more women are able to have VBACs because of this policy change.

July 21, 2010 | Unregistered CommenterVicki

Financial compensation to hospitals may be influencing this ACOG decision as well. If other States and private insurance companies follow the WA trend, doctors will be scrambling to alter their practices.

Article from 2009:
http://crosscut.com/2009/08/06/health-medicine/19144/Take-away-the-incentives-for-too-many-c-sections/

"Beginning this month, the state of Washington will pay hospitals the same amount for an uncomplicated C-section as for a complicated vaginal birth when it reimburses them through Medicaid. Almost half of all births in Washington are paid by Medicaid. . ."

July 22, 2010 | Unregistered CommenterPriss

I am absolutely bouncing, also hopeful that the ACOG will propel the OB/GYN community to be better to women and children.
The community hospital where many of the women in my life have given birth has had a strict "No VBAC" policy for a while... and an excessively high rate of Cesarean (about 35% at last check). There are no midwives in that community and I worry about the mothers and children in our area, more than an hour and a half often from this hospital, who don't have the opportunity to go elsewhere.
I'm an incoming Midwifery Student at Birthwise Midwifery School in Bridgton, ME, and have already agreed to host several TTC friends in my apartment for their homebirths/HBACs provided they have the money and agreement of one of the several midwives working in the area of the school.
Let's wait and see how this affects birth.

July 22, 2010 | Unregistered CommenterBecca

Oh, thank goodness! I'm a Brit who's just moved here, and I was worried that if I ever had a third child, I would get stuck with another caesarean (even though I'm a 'proven pelvis' and in the UK, would be immediately classed as a strong VBAC candidate).

The hospital in the UK where I had my caesarean (for footling breech presentation) told me that they had a 78% success rate with VBACs, so the 60-80% statistic sounds ok to me, if on the low side.

July 22, 2010 | Unregistered CommenterTW

I'm excited that people that want this option have the opportunity. It is important to read this critically:

"but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. ‘It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance,’ "

What are the logistics necessary to mitigate the risks? I suggest that they'd be along the lines of being able to immediately deliver the baby. That requires the availability of an OR in about 90 seconds. Most hospitals will not allow, or are not equipped to have women doing their TOLAC in an OR with an attending physician and anesthesia...

Food for thought....

July 22, 2010 | Unregistered CommenterRachel

Rachel! Don't be a buzzkill! ;P

July 22, 2010 | Registered CommenterNavelgazing Midwife

Hi Barb,
Actually, Rachel is spot on. My local hospital bans VBAC's. My OB and I negotiated a solution of how I could have a VBAC there. This was his offer: I could schedule an induction at 38 weeks. This would ensure a scheduled anesthetist (epidural required upon admittance), surgical team, and an OR would be available for me in case I were to rupture my uterus or my TOLAC failed. Needless to say, I declined his ludricrous offer. A medicalized birth is not far from a c/s birth, in my experience. Think of all the complications that the "plan for a TOLAC" would create? I shudder at the increase in maternal and infant morbidity if women were to aggree to these types of negotiations.

July 22, 2010 | Unregistered CommenterSusie

Barb, I wish this new ACOG Practice Bulletin was really going to change something. But when I read it, sounds like the same old stuff: "A trial of labor after previous cesarean delivery should be undertaken at facilities capable of emergency deliveries. Because of the risks associated with TOLAC and that uterine rupture and other complications may be unpredictable, the College recommends that TOLAC be undertaken in facilities with staff immediately available to provide emergency care." So "immediately available" is the same wording that led to the collapse of VBAC availability in 1999. This wording is what makes it so hard to provide VBAC in hospitals that don't have 24/7 anesthesia, operating room staff, etc. Of course you can argue that such hospitals shouldn't be doing any births at all, but reality is that there are lots of hospitals in this group. And until the liability issue is solved, VBACs won't happen at such hospitals.

July 23, 2010 | Unregistered CommenterRuralObGyn

What about these parts?

"Restricting access was not the intention of the College’s past recommendation. Much of the data concerning the safety of TOLAC was obtained from centers capable of performing immediate, emergency cesarean delivery."

"Health care providers and insurance carriers should do all they can
to facilitate transfer of care or comanagement in support of a desired TOLAC, and such plans should be initiated early in the course of antenatal care."

"Respect for patient autonomy also argues that even if a center does not offer TOLAC, such a policy cannot be used to force women to have cesarean delivery or to deny care to women in labor who decline to have a repeat cesarean delivery. When conflicts arise between
patient wishes and health care provider or facility policy or both, careful explanation and, if appropriate, transfer of care to facilities supporting TOLAC should be used rather than coercion."

July 23, 2010 | Registered CommenterNavelgazing Midwife

Those parts are good but they don't change much for my patients. Since I stopped offering VBAC, I have offered referral to hospitals that do VBAC. A few women wanted VBAC enough to switch. Because they had Medicaid, no private doctor in Nearby Large City would take them. They ended up in the resident clinic of a hospital there, an hour away. Transportation was difficult and as it happened each of these women had another c/s, several times being counseled at the resident clinic to choose another c/s prior to labor. Frustrating for all concerned, showing yet again that solutions to this problem are not simple. I have not yet had a patient in labor want transfer to a hospital that does VBAC, would be glad to transfer her if she wants. As for coercion, that is completely out of line. We can agree that a doctor who forces women to have c/s needs something more basic than an ACOG bulletin.

July 24, 2010 | Unregistered CommenterRuralObGyn

I agree Barbara, that it seems that ACOG is finally at least remotely aware of the far reaching influence of their practice bulletins. I wish their original "immediately available" bulletin had been this nuanced, the new bulletin at least acknowledges that women should not be sectioned against their will and that some facilities will have less than ideal service availability.

But I have to say, I agree with ICAN and rural obgyn - now that such damage has been done to women's access, physician attitudes and hospital policies, it takes more than a revised practice bulletin to make things right. And unless something systematic is done to manage liablity and/or insurance for physicians, they will continue to be highly risk averse.

July 25, 2010 | Unregistered CommenterLarissa

Can you imagine freedom to birth vaginally without nurses pointing fingers and laughing about how unlikely it is for a VBAC mom to birth in a hospital? I don't know if things will change, but if they do this brings up a whole mix of feelings up for me. As a birth assistant/educator who has attempted two homebirths and transferred twice in need of more technology, only to be met with hostility, abuse, threats, punishment and a forced knife. What if I was just a year too late at my chance to use my vagina? Wow....... politics! Who would have thought that they would have such control over our modern day lives. We think we are free, yet I see enslavement of my own reproductive organs.....hmmmmmmm

July 25, 2010 | Unregistered CommenterSavannah

I had a nice chat with my (very pro Vbac) OB today about the new guidelines. He was happy that they came out but not terribly optimistic OB's would go along with them. The fear of litigationt is still so great. He said he already had another doctor in his practice come to him ranting that women would die, uteri would rupture etc....
We also discussed the lack of discussion of complications related to repeat C-section. He said 20 years he never saw the rate of placental complications that he sees now.

July 28, 2010 | Unregistered Commentermom9

I am wondering if this is at all related to the health care reform...some of the language in the bill seemed to be laying groundwork for a much more midwife-based system, which may not be fully developed until the next reform (which I expect will be bring in fully socialized medicine).

July 29, 2010 | Unregistered CommenterPeggy

Here's the part that I find interesting: "Women with an unknown type of uterine scar are appropriate candidates for a TOLAC." I was told that my first c-section was done using an inverse T-shaped incision on my uterus, and that I was therefore not a candidate for VBAC. My first child was born vaginally. Under these new guidelines, could I possibly be a candidate for VBAC if I get pregnant again?

Now that I think about it more, I highly doubt I could find anyone who would let me labor, as I've now had 3 c-sections.

P.S. Just found your blog, Barb, and am enjoying it immensely.

August 8, 2010 | Unregistered CommenterSarah

Cool, Sarah! Thanks for reading. :)

August 9, 2010 | Registered CommenterNavelgazing Midwife

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