In a long overdue updated Practice Guidelines, the American College of Obstetricians and Gynecologists (ACOG) released new guidelines on July 21, 2010 for vaginal birth after cesarean (VBAC). This will hopefully bring some balance to a growing problem for women’s birth choices and changes on the local level.
For many years, VBACs were offered as standard procedure in most American hospitals. The former ACOG guidelines recommended that a trial of labor be offered women who fit the criteria as long as a surgical team could be made ‘readily available’. This generally meant within 30 minutes of determining the need for surgery. Later, the guideline wording was changed to ‘immediately available’ which would have required that any time a woman was attempting a trial of labor for a VBAC, the surgery team had to be on the premises and ready to perform surgery right away. There were apparently no supportive studies to justify the wording change, but it quickly became the standard of care and with those two words came many years of women being forced to submit to repeat surgical birth because of the lack of resources to attempt a VBAC. The new requirement was not practical from the financial or time constraints of the medical facility and physician personnel. It had nothing to do with the safety issues, but was strictly a financial, time, malpractice and legal issue.
The National Institutes of Health met in March 2010 on the topic of cesarean birth and VBAC and made some recommendations because of the concern over the growing number of cesarean births conducted in our country. Recent statistics place cesarean birth at around 31% of all births, but many local facilities’ statistics are much higher. In 1970 the cesarean rate was about 5%. While a cesarean birth is a life-saving surgery if truly necessary, most experts (including the World Health Organization) agree that the legitimate use of cesarean should be between 10-15% of the birthing population, not the high numbers we are now seeing. The overuse of induction, medications (including pitocin and epidurals), subjective interpretation of electronic fetal monitors, confinement of laboring women to bed and lack of trust in a woman’s body to birth normally have led to the use of cesarean section in epidemic proportions. Then because of the lack of VBAC options, women were forced to continue to have repeat cesareans.
The newest guidelines condemn VBAC bans and encourage VBAC as a “safe and reasonable option for most women, including some women with multiple previous cesareans, twins and unknown uterine scars”. It also states that respect for patient autonomy requires that even if an institution does not offer a trial of labor after cesarean, a cesarean cannot be forced nor can care be denied if a woman declines a repeat cesarean during labor. The new guidelines also encourage women and their physicians to make a plan for a trial of labor after cesarean (TOLAC) even in institutions where surgical teams may not be ‘immediately available’. The risk of rupture during a TOLAC is very low, between 0.5% and 0.9%, though circumstances may develop during labor that may require a repeat cesarean delivery.
Women should take the time to educate themselves on their options, discuss and encourage their local care providers and facilities to come into alignment with these newest practice guidelines, and avoid interventions that may lead to a primary cesarean birth unnecessarily. Continued consumer pressure may be the only way real changes in maternity care will occur. For more information, consult International Cesarean Awareness Network at: