Yesterday the American College of Obstetricians and Gynecologists (ACOG) announced that they have changed their recommendation regarding vaginal births after c-sections (VBAC, pronounced vee-back). Where the College was once cautious about this option, it now encourages doctors to support a woman’s choice to try for one.
This is big news in the ongoing debate about maternity care in America. One in three births in America is a c-section, and many of them are repeat c-sections. This new attitude is part of ACOG’s mission to lower c-section rates to a more appropriate level.
“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,” said Shari Roan, writing for the LA Times.
But how much will this new recommendation change things in most American hospitals? And how does a woman make the choice between a VBAC and a repeat C?
A little history: In the ’60s and ’70s, it was “once a c-section, always a c-section,” but in the ’80s, VBACs started gaining popularity. By the mid-1990s a “trial of labor” (attempting a VBAC) was recommended by ACOG and mandated by some insurance companies to help keep costs down.
This policy coincided with the increased use of medications used to start or speed up labor, including the controversial, off-label use of Cytotec. Cytotec has never been FDA-approved for use in labor, but it was cheap and worked well. Soon it became clear, however, that for women who had scars from previous surgery, Cytotec was very dangerous, sometimes leading to uterine rupture — a serious and sometimes fatal consequence.
Now Cytotec is not used for VBACs, but over the course of all those mandated trials of labor, there were some startling, high-profile cases of maternal and perinatal deaths. VBACs got a bad name. ACOG responded by insisting that if done, an emergency surgical team needed to be “immediately available.”
From a legal standpoint, this made VBAC a risky choice for OB/GYNs. What if you are practicing in a small- or medium-sized hospital where you cannot expect a c-section team to be ready and raring at the drop of a hat? Well, you’d be breaking with ACOG guidelines and putting yourself in danger of a lawsuit.
Over the last decade, it’s become very hard to have a VBAC. I know people who have done it, but they’ve often had to fight to some extent to get support. Still, there have always been doctors and midwives who support VBACs, and that’s because a risk/benefit analysis of VBAC vs. repeat c-section does not easily point to a safer route.
The primary risk with a VBAC is “uterine rupture” — the chances are at about 0.5 percent or 1-200. If no drugs are used for labor induction, the uterine rupture rate is even lower. According to the International Cesarean Awareness Network (ICAN): “The rate of rupture in a VBAC labor which is not induced is only 1/2 of one percent, less than your risk of experiencing several other major childbirth complications.” Labor-stimulating drugs, while generally safe and sometimes beneficial, can cause stronger contractions than in non-medicated labor.
According to the numbers ACOG is using, if you try for a VBAC, you have about a 99.2 percent chance of no uterine rupture (lower without induction). If you have a c-section, you have about a 99.5 percent chance of no uterine rupture. That would make the chance of a uterine rupture with a repeat c-section and VBAC without induction about the same. But with a c-section, you have the added risks of surgery.
Another fear is the consequence of rupture, brain damage or fatality. But according to Jennifer Block, author of Pushed, “the rate of neonatal brain damage or death among VBAC attempts was consistently about 1-2000. Those are excellent odds — the risk of a U.S. baby not surviving labor in a low-risk birth is about 1-1000.”
Another number to consider: If you try for a VBAC you have a 60-80 percent of having one — some say more like 75 percent. If the first c-section came after a particularly demanding and/or very long labor, the idea of another long labor followed by a c-section — even if that chance is only 25 percent — might be, understandably, hard to accept.
I think the decision about whether or not to VBAC is something we have to leave up to each woman. She should be well-informed rather than freaked out and/or pressured by various agendas, and she should find a doctor or midwife who supports her decision, whatever it is. ACOG seems to be saying as much:
“The current cesarean rate is undeniably high and absolutely concerns us as OB/GYNs,” said Richard N. Waldman, MD, president of ACOG. “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 patients and our colleagues, hospitals and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate.”
But some are skeptical that there really will be a choice.
For her New York Times coverage, Denise Grady gathered a number of quotes from childbirth advocates and obstetricians, stating that because ACOG is still asking that a back-up surgical team be “immediately available,” not that much is going to change. The mood may be shifting toward VBAC, but the legal environment hasn’t budged. Plus, though the opening of doors to VBACs is a welcome idea, the language used in ACOG’s press release indicates that that door can pretty easily slam shut:
“…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 ["trial of labor after cesarean"]. 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.” (My emphasis.)
In all, I’d like to think of this as good news. A big part of the VBAC debate has been an overwhelming feeling on the part of most people that it’s just a crazy-person risk to try for one. The fact that ACOG is acknowledging the evidence supporting a VBAC is a good thing. And steps to bring the c-section rate down are steps in the right direction. I am also impressed with ACOG’s encouragement of informed choice. It’s still not an easy choice to make for some women, and I entirely empathize.
It’s for this reason that I’ll end by directing anyone making the decision to the resources at Childbirth Connection, which provide excellent advice for getting the best out of a either a VBAC or a repeat c-section.