June 16, 2010

ACOG on VBAC: In Their Own Words

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?


9 Responses to “ACOG on VBAC: In Their Own Words”

  1. Kendra Says:

    It’s a start, but this bothers me tremendously:
    “Any time we are tempted to take the safe path but not the righteous path”???

    For most women, vaginal birth is both the safe AND righteous path. According to the WHO, a “safe”, do-no-harm cesarean rate is 15%. Maybe he means *safer* from lawsuits? How about not to electively induce or perform an elective cesarean. (period! and lose the “prior to 39 weeks” addendum) That would help quite a bit toward the previous recommitment of not performing unnecessary surgery! Since when did the timer start to ding at 39 weeks?

    OBs should look to take the “patient” path – both in looking to their patients’ rights and cues, and also in figuring out when the best thing to do is to sit on their hands and wait!

  2. Rachel Says:

    Thanks for your comment, Kendra. In the context of the full piece, I believe the author was saying that the physician’s impulse to do cesareans just to be “safe” may not be the “righteous” choice, but I can see how that might be unclear because it doesn’t clearly tease out the difference between a provider’s perception of safety vs. actual safety for the woman.

  3. Susan Jenkins Says:

    I, too, have read Dr. Scott’s editorial and Dr. Waldman’s address and feel encouraged. I want to point out to everyone reading this blog, however, that there are now two ACOGs. ACOG split recently into two entities, a 501(c)(3) educational entity to continue with the name American COLLEGE of Obstetricians and Gynecologists, and a separate trade association, American CONGRESS of Obstetricians and Gynecologists, which will be the lobbying arm. Sort of good twin/evil twin — or good cop/bad cop.
    Dr. Waldman, the let-us-reason-together guy, is the president of the College twin, the twin that recently reached out to ACNM to work together on finding ideal collaborative models. He sounds pretty reasonable and I hope something good comes of that. But notice that the evil twin, ACOG the Congress, just last week — as Dr. Waldman’s letter was circulating on the internet — was lobbying against the bill that would allow New York midwives to practice without those anachronistic anti-competitive written practice agreements, just as it has lobbied against autonomous midwifery practice in Massachusetts. Since Dr. Waldman practices in New York State and has midwives working in his practice, it would be interesting to hear his take on the position that ACOG the Congress has taken on the New York bill.
    Thanks for this opportunity to warn readers of this great blog that, from now on, when you read or hear about ACOG, double-check on which tricky twin is speaking or being spoke of.
    Love to all at OBOS from the Big Push for Midwives Campaign.
    Susan

  4. Rachel Says:

    Hey, Susan, thanks for your comment/clarification about the “two ACOGs” – this is bound to cause some confusion going forward given the identical abbreviations.

  5. Melissa Says:

    Could the “safe” path be referring to what’s most likely to not result in a lawsuit rather than what is safest for the woman and her baby?

  6. Rachel Says:

    Melissa, that’s exactly how I read the author’s statement, too.

  7. Donna Says:

    In one of the articles which led me to this blog, the author stated that VBAC is commonly perceived as risky, and that we needed to think outside the box on this issue.

    I worked with Bruce Flamm’s research on the safety of VBAC in the very early 90s, and from there the medical evidence has not wavered much. Anybody who looks into objective stats about safety of VBAC should come up with numbers which support trial of labor. As a childbirth and VBAC instructor at a major LA hospital, my feeling is that the perception of risk is propagated by the MDs themselves, because I have read next to nothing that touts VBAC as any more dangerous than repeat C, and most reports say it’s safer.

    I have students whose MDs tell them that they are risking their babies’ lives by wanting a VABC. I have students who have to change MDs two or three times in their pregnancies to find a doc who is supportive of VBAC. I have students whose MDs schedule a repeat C for them but tell them that they support VBAC. I have students whose MDS tell them they can have a VBAC, but only if they go into spontaneous labor before 39 weeks…if not, they’re scheduled for a C. We have an MD who had two VBACs herself and tells her patients, if I knew now what I knew then, I’d have had repeat Cs. (Needless to say, I no longer refer people to this doctor as VBAC-friendly!)

    All that being said, and reading the above comments, when I try to put myself in the OBs’ shoes, and with all the info I’ve read about the anguish and even ruining of careers, marriages and lives that can come with lawsuits that drag the MD through the mud and back, in my heart I can understand defensive practice, and the truth is that nobody seems to sue for doing an unnecessary C, but plenty of people sue for not doing a necessary one.

  8. Bonnie Says:

    The fact that this doctor whom some have seen as reasonable and kind can say that it might be : “Any time we are tempted to take the safe path but not the righteous path,”It would be better to take the righteous one.

    So, does he mean the safe one would have protected HIM and other O.B.s? He must. Because any well educated childbirth proponent knows that it is NOT as safe to have a C-section as a vaginal birth.

    All this horrible induction and counting the days past an IMAGINARY due date is just plain wrong.

    Let nature take it’s course.

    That could not possibly be worse for women (or their babies) than the over medicated births that the USA is providing these days.

  9. Rachel Says:

    Yep, I believe the author is talking about “safe” for providers (legally).

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