New VBAC recommendations from ACOG

In July 2004 the American College of Obstetricians and Gynecologists issued practice bulletin #54 - which changed the status quo for treatment of women with a history of prior cesarean.  The big change was that ACOG recommended that women attempting a vaginal birth after cesarean (VBAC) should labor with a "physician immediately available throughout active labor capable of monitoring labor and performing an emergency cesarean delivery."

The big word there was "immediately".  It appears exactly once in the practice bulletin but it is an important word.  It caused a string of practice changes for obstetricians, policy changes for hospitals and health outcome changes for pregnant women.  In short, the VBAC rate plummeted and hospitals demanded that women submit to surgery.

Yesterday, ACOG issued a new practice bulletin, #115, that they intend to replace the infamous bulletin #54.  This bulletin doesn't seem to remove the damning word (though I just read the press release, it costs $ to order the active bulletins).

This time the press release opens with, "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"


But it also uses the word "immediately" three times.  And while ACOG acknowledges that women should not be forced to submit to surgery in hospitals that do not have "immediately available" staff, they are rather vague about what an acceptable plan for these facilities would be for women undergoing a trial of labor after cesarean.  


I appreciate the more nuanced understanding that ACOG has demonstrated with this new practice bulletin.  Maybe they are beginning to recognize the serious impact these statements have on the care women receive across our country.  I certainly hope so.


However, this is not a situation in which the organization can simply say "Our bad" and undo all the damage that has been done by bulletin #54.  It would be nice if we could just "withdraw from circulation" (see here) the fear and ingrained policies and the lack of access that #54 has visited upon American women.  


We know that women who have given birth by cesarean are less likely to choose or achieve another pregnancy and that their subsequent pregnancies are subject to greater risks.  We know that the more cesareans a woman has, the more dangerous it is.  We know that #54 increased the number of cesareans that were performed on women.  We know that #54 was a mistake, and now ACOG has admitted it.


But admitting a mistake and even rectifying that mistake with a nuanced and understanding new practice bulletin doesn't undo the damage of that mistake.  #115 isn't going to be able to undo all the havoc #54 has wrecked upon American maternity care.


 We need a comprehensive approach to cesarean reduction, we need consumer education, targeted interventions for women with prior cesarean, policy reviews at hospitals, practice standards for physicians (set by the physicians themselves, I'm not trying to tell anyone how to practice medicine) and we need public access to cesarean data so that consumers can make truly informed decisions.  


#115 is a nice start, but it doesn't have the chops to undo what #54 has brought down upon us.  So thanks, ACOG, for a great start.  What else have you got for us?