Vaginal Birth after Cesarean -- What the NIH has to say

As many of our readers will already know, the National Institutes of Health held a consensus development conference last week on vaginal birth after cesarean in the U.S., featuring panelists who spoke about VBAC trends, medical evidence, risks and benefits to women and babies, non-medical factors influencing VBAC availability (such as fear of legal liability), and related topics.

Materials from the conference are available at http://consensus.nih.gov/2010/vbac.htm, including the draft panel statement, archived webcasts from each day of the conference, the previously completed evidence report on VBAC, and call-in access to the archive of a telebriefing that followed the event wrap-up (a transcript will be available soon).

One important topic included perceptions of the risk of trial of labor; a speaker who reviewed factors associated with uterine rupture and other adverse outcomes stated that “there is a major misperception that trial of labor is extremely risky,” calling the risks to women comparable to other common medical procedures. Amy Romano provides additional commentary on uterine rupture risk at Science & Sensibility, noting that “we heard a rather consistent message that uterine rupture itself is not the issue.”

There was an excellent audience question following the presentation about whether, if successful VBAC carries the lowest morbidity, it is ethical for providers to refuse to allow a trial a labor. One panelist’s response was, “I think that’s the point of the conference.” Audience discussion sections for day one start at about 1:41, 3:01, 4:03, 5:55, and 7:19 [hour:minute].

Day one also featured another presenter, Dr. George Macones, who challenged ACOG’s “immediately available” physician and anesthesiologist standard for offering VBAC. This requirement has effectively led to the restriction of VBAC around the U.S.; Dr. Macones called it “overkill,” and argued that “the risk of rupture is comparable to other bad things that happen in labor that lead to an emergency cesarean section.”

As examples, he noted that prenatal diagnosis for Down Syndrome via chorionic villus sampling is routinely offered to all pregnant women and carries a 1% pregnancy loss rate, and external cephalic version requires immediate c-section about 1-3% of the time, making the risks from VBAC not that different from other things that are done “all the time” in obstetrics.

Day three generated perhaps the most heated discussion, in which a panelist stated that it is not a settled matter that women have a right to refuse a cesarean, reminding us of the need to continue to advocate for choices and rights for childbearing women. The relevant audience question comes up at 1:47:20 and comes from Shannon Mitchell of BirthAction. She raises the concern that there is nothing in the draft document that says that women have the right of refusal of a cesarean, an issue of concern given reports of court-ordered cesareans. The moderator refers the question to a medical ethicist, who responds:

That’s a very large topic in obstetric ethics there’s not a settled answer to it. There’s actually — contrary to what you heard yesterday — some serious disagreement in the obstetric ethics literature, but in any case I think it’s beyond the charge of this panel to take that question up.

Courtroom Mama provides further discussion of this issue at The Unnecesarean, including additional commentary from the telebriefing.

Despite this comment on women’s right to refuse a repeat cesarean, I hope that the conference will lead providers and institutions with codified or de facto VBAC bans to reconsider their policies and attitudes. I’m encouraged by this statement from the conclusions of the draft panel statement:

We are concerned about the barriers that women face in accessing clinicians and facilities that are able and willing to offer TOL [trial of labor]. Given the level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement relative to other obstetrical complications of comparable risk, risk stratification, and in light of limited physician and nursing resources. Healthcare organizations, physicians, and other clinicians should consider making public their TOL policy and VBAC rates, as well as their plans for responding to obstetric emergencies. We recommend that hospitals, maternity care providers, healthcare and professional liability insurers, consumers, and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to TOL.