Monday, July 26, 2010

ACOG's Bittersweet VBAC Statement Issued July 21, 2010

The American College of Obstetricians and Gynecologists (ACOG) issued a long-overdue statement this week regarding Vaginal Birth After Cesarean (VBAC):  "Attempting a vaginal birth after cesarean is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today...  The College 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...  These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy.  Moving forward, we need to work collaboratively with our patents and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate..."

OK.  My reaction after reading their statement should have been joy.  The natural birth community has waited a long time for this.  To be honest, my initial reaction was anger, followed by sadness.  My eyes even welled with tears thinking of all the millions of women who have been lied to for the last decade about how risky VBACs are and as a result had unnecessary surgery.  Babies suffered.  Mothers suffered.  Doctors benefited. 

We have a generation of doctors who now believe that VBACs are risky -- because ACOG said so for so many years-- and now they are being told that they are not dangerous and to go ahead and allow women a TOLAC (Trial of Labor After Cesarean).  I probably don't need to tell you that a trial of labor can easily make an OB look like he tried to allow a VBAC and (s)he may have no intention of allowing moms to VBAC.  If you are in this situation, ask your care provider what a "trial of labor" means to them.  Will you have time limits imposed on your labor?  Likely.  Do you require continuous monitoring?  Can you get up and walk around?  Are they going to treat you  like a "normal" woman in labor or like an accident waiting to happen -- IV fluids, restricting food and water, continuous monitoring, regular vaginal exams, etc. -- because attitude is everything when a woman is VBACing.  She requires a lot of emotional support.

Who is going to be involved in these changes?  It's not just about an OB and his patient.  It's about hospitals and insurance companies.  There are more than 800 hospitals across America that have banned VBACs over the last decade, the majority of those fairly recently.  Can we expect these changes to be immediate?  Unfortunately, probably not.  If you are a VBACing woman, be very familiar with this statement and fight for your right to a VBAC.  That is probably the first step.  Change is not going to occur immediately.  Women may even find themselves quoting this statement to their insurance companies.

I believe that what led to this statement was not evidence or the demand for VBAC by women.  The evidence against repeat cesareans is strong and always has been.  What led to this statement was another agency getting involved in the cesarean epidemic.  The National Institute of Health (NIH) held their conference in March and at the top of the list was addressing America's insanely outrageous c-section rate.  The number one reason for a cesarean is because a woman has already had a c-section.  If we could raise the VBAC rate, we'll automatically lower the cesarean rate, improving lives while saving money all at once.  A win-win. The statement had to come from ACOG.  The pressure was on.

According to the statement issued, 60-80% of women who attempt a VBAC will be successful.  I interviewed a group of CNMs in Albuquerque several years ago who loved doing VBACs, and as a result, their VBAC rate was 92.3%.  The care providers in the DFW area who support VBACs also boast 90%+ VBAC rates.  The Mother-Friendly guidelines state that the VBAC rate should be at least 60%.

I have written about the safety of VBACs in the past, so I wont rehash that here.  You know what I believe.  There are a couple more quotes I think are worth repeating here that appeared in the statement.

"Our primary goat is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC."   However, in another paragraph, it says "The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available."  (Remember, the risk of uterine rupture is between 0.5% and 0.9%.)  A statement very similar to this is what led to the VBAC bans in so many hospitals.  Not crazy about it appearing in the statement.  I think we'll see doctors referring to it in defense of continuing with not allowing VBACs. 

The last paragraph 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."  I could not help but think of Allison's story I wrote about last year.  How things would be different for her if this statement had been issued less than a year ago.  Honestly, it makes me feel sick, angry, and sad.  I called her tonight after rereading the statement.  She had read it this afternoon.  We had the what-might-have-been conversation.  It's a moot point.  But now she has 3 cesareans under her belt (pardon the pun -- really not trying to be funny here), but the statement doesn't address women with more than 2 c-sections.  But because she was literally forced into the third c-section solely because of a hospital policy, if they decide to have another baby, she is still going to have to fight for a VBAC. 

So, yes, I am glad that ACOG issued the statement.  The price was high.  Women, I believe, are still going to have to fight to make this a reality.  A friend of mine, former Bradley student turned Bradley teacher, Sarah Clark, aka Mama Birth, titled her post on this topic "ACOG Still Sucks."  And that about sums it up...


roadrunner201 said...

Newly affiliated Bradley instructor giving you a standing ovation over here. This was so well said. I grieve for all the mamas who desperately wanted a vbac, but were scared into believing them unsafe.

Anonymous said...

Just pointing out that ACOG no longer stands for the American "College" of Obstetrics and Gynecology, but rather the American "Congress" of Obstetrics and Gynecology. I know it's a bit nit-picky of me, but the word "congress" is more appropriate for a group who lobby for the political leanings of their affiliate than the word "college" is, which implies some sort of educational focus. We all know that ACOG's motivation is rarely has anything primarily to do with education, but rather with what's in the best interest of it's members (the OB/GYN's).
I've been disgusted with ACOG since they changed the recommendation for VBAC from having a surgical team "readily" available to having one "immediately" available throughout if emergencies don't pop up in first-time vaginal births. In my humble opinion, this latest release doesn't redeem them. Your friend had it right, they still suck.

Katie said...

I know this comment isn't pertinent here but had trouble with your email.

I wanted you to know we had a wonderful, 12 day post due date, home birth. On Tuesday mornign we joyfully welcomed our son into the world. Check out photos on our blog

No birth story yet, but it's coming. Isn't it CRAZY we have a 'mutual' friend, what a small world! Thanks for inspiring me to begin this journey.

Angel said...

It's not necessarily the docs that need convincing... it's the malpractice insurance that aren't letting... they tell the docs no who in turn tell us no. it's complete bull )*^% if you ask me. esp since my hubby seems to think that my doc is the best in the state (his words) and will do whatever she says if it benefits him. she did tell him to get our 4 year old into her own bed before the twins come, but he's ignoring that. i'm starting to want to fire them both.