Via the blog Birthing Beautiful Ideas, we were alerted to two interesting pieces in the current issue of Obstetrics and Gynecology, the journal of the American College of Obstetricians and Gynecologists, that may indicate a shift in thinking about hospital staffing protocols for a vaginal birth after a c-section.
In 1999 (and again in 2004), ACOG released guidelines [pdf] stating that “VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available.” This standard has been widely blamed for the lack of VBAC availability in many parts of the United States, as many hospitals discouraged or stopped doing VBACs, and in some cases malpractice insurance companies refused to cover claims resulting from the procedure.
As Rita Rubin explained in a 2005 USA Today story on the issue, “Many hospitals have interpreted that [the 'immediately available' standard] to mean they must have an anesthesiologist and operating room standing by whenever a patient attempts a VBAC, a luxury they say they can’t afford. If they can’t meet the guidelines, they argue, they’re opening themselves up to lawsuits should mother or baby be injured during a VBAC attempt.”
In an Obstetrics and Gynecology editorial titled “Solving the Vaginal Birth After Cesarean Dilemma” (only available with login or payment, unfortunately), journal editor James R. Scott, M.D., references the “immediate availability” standard on VBACs:
Although all guidelines have been well intentioned, each new set resulted in unintended consequences. Today, the VBAC issue remains contentious and unresolved. Many hospitals no longer allow VBAC because they are unable to provide the level of response recommended, and some insurance carriers prohibit physicians from performing VBAC. Consequently, trial of labor after cesarean is now denied to many women who strongly desire this option and to physicians who want to provide it.
Scott’s conclusion sounds very much like something OBOS could agree with (emphasis added):
What level of risk is acceptable, and who decides? Currently, hospitals, insurance companies, and plaintiff attorneys decide or strongly influence whether VBAC is an option. Instead, the patient should be allowed to make that choice after she has been informed of the facts and has been counseled by her physician thoroughly.
“Despite the reality of disparate resources, we should ‘find a way’ for those who want the option of VBAC,” Scott continues. “Reducing the number of primary cesareans deals with the problem where it originates.”
The second piece of interest is a synopsis of the address that ACOG’s president, Richard Waldman, MD, delivered at ACOG’s 2010 annual meeting. In his remarks, Waldman calls for better data about birth and raises concerns about maternal mortality and high cesarean rates. On this last point, he states:
In 2008 the cesarean delivery rate reached another record high—32.8% of all births. There is a community not far from my home in which 45% of the newborns are delivered via an abdominal incision. [...] Liability dampens our spirits but unfortunately, it is also starting to define our specialty. [...] Let us recommit to do everything in our power to perform surgery only when necessary. Let us recommit to induce only when indicated and let us vow to never electively induce or perform an elective cesarean prior to 39 weeks. Any time we are tempted to take the safe path but not the righteous path, we should all say, “not on my shift.”
Each of these statements seems to reflect concerns about limited VBAC options that birth advocates and others have been expressing for some time. Who wants to take bets on whether they’re also laying the groundwork for an updated — and perhaps more permissive — VBAC recommendation?