Has ACOG Been Listening to Birth Advocates?
The June 2010 issue of Obstetrics & Gynecology–or “The Green Journal,” the American College of Obstetricians and Gynecologists’ (ACOG) research publication–includes three articles that address vaginal birth after cesarean (VBAC).
One is a research article addressing maternal and neonatal outcomes associated with VBAC.
One is a letter, written by the president of ACOG (Dr. Richard Waldman), addressing the social and practice changes ACOG members can make to improve both their professional climate and the birthing climate for their patients. (This letter is also a synopsis of his 2010 inaugural address.)
And the other is an editorial (entitled “Solving the Vaginal Birth after Cesarean Dilemma”) written by the journal’s editor-in-chief, Dr. James R. Scott, MD.
This editorial begins by addressing the NIH Consensus Development Conference on VBAC and the accompanying NIH Statement on VBAC. And in the spirit of the NIH Statement, Dr. Scott’s piece was a (surprisingly) refreshing read.
In fact, in many ways Dr. Scott’s editorial simply reiterates many of the points made by the NIH panel in their statement on VBAC.
And this isn’t in any way a “bad thing,” in my humble opinion.
For in barely a page-and-a-half, he makes sure to point out that:
- The “immediately available” language in the 1999 ACOG Practice Bulletin on VBAC had the “unintended consequence” of leading to a drastic reduction in the number of hospitals and care providers that support VBAC.
- …”the overall risk for perinatal mortality and morbidity with trial of labor is similar to that for any nulligravid woman in labor.” (In layperson’s terms, a “nulligravid” is a woman who has never given birth. So what this means is that if you were to attempt a VBAC, you would face a risk of perinatal mortality and morbidity that is similar to the same risk faced by a woman having her first baby.)
- The “immediately available” standard seems incongruously applied to VBACs when one takes into account non-VBAC related obstetric emergencies such as cord prolapse and placental abruption. Both of these emergencies, which can happen during any attempted vaginal birth, occur nearly as frequently as uterine rupture, and both have similar (if not “worse”) perinatal morbidity and mortality rates. In this respect, the “immediately available” standard (which requires an OB/GYN and an anesthesiologist to remain “in-house” throughout active labor) is unfairly applied to VBACs.
- Limited hospital staff resources make it impossible for the “immediately available” standard to be applied to all hospitals that offer labor and delivery services, both now and in the future. Thus, the “solution” to the aforementioned incongruity isn’t to apply this standard to all vaginal births.
- The choice between VBAC and repeat cesarean delivery is ultimately the woman’s choice. And she should receive accurate information from her care provider so that she can make an informed decision.
- OB/GYNs should “‘find a way’ for those [women] who want the option of VBAC.” (Dr. Scott recommends that hospitals incapable of providing 24/7 anesthesia should consult the New England Perinatal Quality Improvement Network VBAC program for recommendations on safely supporting VBAC.)
- We cannot fully address the issue of VBAC without also addressing (and finding ways to reduce) the rising primary cesarean rate.
- And finally, “unless measures are instituted to reverse the rapidly rising cesarean rate, catastrophic complications from placenta accreta and percreta associated with multiple repeat cesareans soon may be a greater problem than uterine rupture.”
Dr. Scott is not the first person to make any of these claims.
In fact, many birth advocates have been making them for years.
But I’m happy to know that the editorial staff of Obstetrics & Gynecology is stating these claims loud and clear for all of their readers: that is, for all of the members of ACOG, many of whom currently deny their patients the opportunity to even choose a vaginal birth after cesarean.
Now let’s just hope that there is a noticeable uptake to Dr. Scott’s remarks.