Has ACOG Been Listening to Birth Advocates?

Has ACOG Been Listening to Birth Advocates?

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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:

  1. 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.
  2. …”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.)
  3. 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.
  4. 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.
  5. 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.
  6. 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.)
  7. We cannot fully address the issue of VBAC without also addressing (and finding ways to reduce) the rising primary cesarean rate.
  8. 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.



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10 Comments

  1. Sheridan
    Sheridan06-08-2010

    Great to hear. I hope they actually read it an apply it!
    Sheridan´s last blog post ..Hypnobabies for Snorkeling?

  2. Ren
    Ren06-09-2010

    I feel cautiously encouraged by this, Kristen. I think the experiences of women I know (and myself, to a much more limited extent) have made me so deeply suspicious of the medical establishment on these matters that I can’t get too excited. But what you relate here does seem promising.

    Oh, and on a semi-related note – Dr. B left the WWP, which makes me feel a LOT better about staying with them :)

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas06-09-2010

      I know what you mean, Ren. I definitely read these pieces with cautious optimism.

      On the other hand, there have been some landmark editorials in this same journal that have (in my opinion) contributed to the current hostile VBAC and birthing climate. To see one like this was particularly heartening.

  3. Rixa
    Rixa06-09-2010

    Do you have the full-text of those articles/letters/etc that you could send to me? I’d love to read them.
    Rixa´s last blog post .."Breast is Best" instructional video

  4. Brandi
    Brandi06-09-2010

    I was wondering the same thing as Rixa. I was able to get the first paper but not the letter or last one. I am working to reverse the VBAC ban in our hospital here and this would go a long way in our efforts. I’m printing the NIH statement right now and would love to include these in our “report”. Thanks so much for all you do! I love your site and use it all the time for work.

    Brandi

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas06-09-2010

      Brandi, I’m so excited that you’re working to reverse a VBAC ban!!! What an incredible (and admirable) task you’re taking on–and how WONDERFUL for all of the women that your hospital serves!

      You know, to be honest, I don’t have permanent access to the online editorial or the letter. A friend who is a Green Journal subscriber allowed me to read the articles, but I don’t have her password (or a subscription, for that matter) and I doubt she’d want me to share it with everyone even if I did. :-) Let me see what I can do, however. Maybe we can even write a letter to the journal requesting that they make the letter available to the public!

  5. Jill--Unnecesarean
    Jill--Unnecesarean06-11-2010

    I have Dr. Scott’s (awesome) editorial scanned if anyone wants it. Let me know if you do.
    Jill–Unnecesarean´s last blog post ..Do Overweight Pregnant Women Need Separate High-Risk Hospitals?

    • BirthingBeautifulIdeas
      BirthingBeautifulIdeas06-11-2010

      THANKS, Jill!!

      FWIW, I’ve also contacted the editorial staff at the Green Journal to request that they make the online version of the editorial available to the public. Haven’t heard back from them yet, but I’ll let you all know when I do!

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