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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.