The American College of Obstetricians and Gynecologists (ACOG) has released a new set of guidelines for providers on vaginal birth after cesarean (VBAC). The guidelines should be of interest to anyone who is interested in having a VBAC or who has been concerned about VBAC access and high repeat cesarean rates.
The guidelines, noting the decreasing VBAC rate, increasing cesarean rate, and lack of access to a trial of labor at some hospitals, takes an approach that clearly emphasizes individualized decision-making (rather than blanket policies) and women’s autonomy.
First, the document recognizes that desire for VBAC is not simply a lifestyle choice or preference, but one with implications for women’s health and outcomes:
In addition to providing an option for those who want the experience of a vaginal birth, VBAC has several potential health advantages for women. Women who achieve VBAC avoid major abdominal surgery, resulting in lower rates of hemorrhage, infection, and a shorter recovery period compared with elective repeat cesarean delivery. Additionally, for those considering larger families, VBAC may avoid potential future maternal consequences of multiple cesarean deliveries such as hysterectomy, bowel or bladder injury, transfusion, infection, and abnormal placentation such as placenta previa and placenta accreta.
The authors explain further that, “VBAC is associated with fewer complications, and a failed TOLAC [trial of labor after cesarean] is associated with more complications, than elective repeat cesarean delivery. Consequently, risk for maternal morbidity is integrally related to a woman’s probability of achieving VBAC.”
It goes on to review a number of factors that may be associated with a woman’s likelihood of successfully having a VBAC after a trial of labor, emphasizing the need to examine the clinical picture for an individual woman with regards to the potential benefits and harms of elective repeat cesarean, VBAC, and failed trial of labor. Again, there is explicit consideration for individual autonomy, with the statement that “The balance of risks and benefits appropriate for one patient may seem unacceptable for another.”
With regards to who may be a good VBAC candidate, the document states that “The preponderance of evidence suggests that most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about VBAC and offered TOLAC,” and reiterates that “Individual circumstances must be considered in all cases.”
This recommendation was actually present in the previous (2004) recommendation, but was offset by the so-called “immediately available” standard which led many facilities to decide that offering VBACs was not an option.
The current document states that “Restricting access was not the intention of the College’s past recommendation.” It clarifies that while facilities offering trials of labor should have “staff immediately available to provide emergency care,” when organizing transfers to better equipped facilities is not realistic, “Respect for patient autonomy supports the concept that patients should be allowed to accept increased levels of risk.” Patient counseling and early conversations between the woman and her provider are urged, with the ultimate decision to be “made by the patient in consultation with her health care provider.”
Patient education and access to trial of labor is emphasized throughout, and I think this is the key portion for those concerned about autonomy and forced or court-ordered cesarean:
…none of the principles, options, or processes outlined here should be used by centers, health care providers, or insurers to avoid appropriate efforts to provide the recommended resources to make TOLAC as safe as possible for those who choose this option….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.
Also of interest may be the conclusions that women with two previous low transverse incisions, carrying twins, or with single previous cesarean with an unknown type of incision may be candidates for a trial of labor.
Overall, I think the new practice bulletin is going to be much more agreeable to advocates and useful as a tool in encouraging hospitals and providers to reconsider their VBAC practices. We look forward to hearing your take in the comments!