|
For
Release:
|
July
21, 2010
|
Ob-Gyns Issue Less Restrictive VBAC Guidelines
Washington, DC -- Attempting a vaginal birth after cesarean (VBAC) is a safe and
appropriate choice for most women who have had a prior cesarean delivery,
including for some women who have had two previous cesareans, according
to guidelines released today by The American College of Obstetricians and
Gynecologists.
The cesarean delivery
rate in the US
increased dramatically over the past four decades, from 5% in 1970 to
over 31% in 2007. Before 1970, the standard practice was to perform a
repeat cesarean after a prior cesarean birth. During the 1970s, as women
achieved successful VBACs, it became viewed as a reasonable option for
some women. Over time, the VBAC rate increased from just over 5% in 1985
to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell
to 8.5%, a decrease that reflects the restrictions that some hospitals
and insurers placed on trial of labor after cesarean (TOLAC) as well as
decisions by patients when presented with the risks and benefits.
"The current
cesarean rate is undeniably high and absolutely concerns us as
ob-gyns," said Richard N. Waldman, MD, president of The College.
"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."
In keeping with past
recommendations, most women with one previous cesarean delivery with a
low-transverse incision are candidates for and should be counseled about
VBAC and offered a TOLAC. In addition, "The College guidelines now
clearly say that women with two previous low-transverse cesarean incisions,
women carrying twins, and women with an unknown type of uterine scar are
considered appropriate candidates for a TOLAC," said Jeffrey L.
Ecker, MD, from Massachusetts General Hospital in Boston and immediate
past vice chair of the Committee on Practice Bulletins-Obstetrics who
co-wrote the document with William A. Grobman, MD, from Northwestern
University in Chicago.
VBAC Counseling on
Benefits and Risks
"In making plans
for delivery, physicians and patients should consider a woman's chance of
a successful VBAC as well as the risk of complications from a trial of
labor, all viewed in the context of her future reproductive plans,"
said Dr. Ecker.
Approximately 60-80% of appropriate candidates who
attempt VBAC will be successful. A VBAC avoids major abdominal surgery,
lowers a woman's risk of hemorrhage and infection, and shortens
postpartum recovery. It may also help women avoid the possible future
risks of having multiple cesareans such as hysterectomy, bowel and
bladder injury, transfusion, infection, and abnormal placenta conditions
(placenta previa and placenta accreta).
Both repeat cesarean
and a TOLAC carry risks including maternal hemorrhage, infection,
operative injury, blood clots, hysterectomy, and death. Most maternal
injury that occurs during a TOLAC happens when a repeat cesarean becomes
necessary after the TOLAC fails. A successful VBAC has fewer
complications than an elective repeat cesarean while a failed TOLAC has
more complications than an elective repeat cesarean.
Uterine Rupture
The risk of uterine
rupture during a TOLAC is low—between 0.5% and 0.9%—but if it occurs, it
is an emergency situation. A uterine rupture can cause serious injury to
a mother and her baby. The College maintains that a TOLAC is most safely
undertaken where staff can immediately provide an emergency cesarean, but
recognizes that such resources may not be universally available.
"Given the
onerous medical liability climate for ob-gyns, interpretation of The
College's earlier guidelines led many hospitals to refuse allowing VBACs
altogether," said Dr. Waldman. "Our primary goal is to promote
the safest environment for labor and delivery, not to restrict women's
access to VBAC."
Women and their
physicians may still make a plan for a TOLAC in situations where there
may not be "immediately available" staff to handle emergencies,
but it requires a thorough discussion of the local health care system,
the available resources, and the potential for incremental risk. "It
is absolutely critical that a woman and her physician discuss VBAC early
in the prenatal care period so that logistical plans can be made well in
advance," said Dr. Grobman. And those hospitals that lack
"immediately available" staff should develop a clear process
for gathering them quickly and all hospitals should have a plan in place
for managing emergency uterine ruptures, however rarely they may occur,
Dr. Grobman added.
The College says that
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. 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.
Practice Bulletin
#115, "Vaginal Birth after Previous Cesarean Delivery," is
published in the August 2010 issue of Obstetrics
& Gynecology.
The American College of Obstetricians and
Gynecologists is the nation's leading group of physicians providing
health care for women. As a private, voluntary, nonprofit membership
organization of approximately 53,000 members, The American College of
Obstetricians and Gynecologists strongly advocates for quality health care
for women, maintains the highest standards of clinical practice and
continuing education of its members, promotes patient education, and
increases awareness among its members and the public of the changing
issues facing women's health care.
|