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?

Pseudo-live Blogging - Maternal morbidity elevator speech

What is the one thing I'd say to a woman on an elevator about her risks from cesarean delivery?

"Try really hard not to have a cesarean.  It can be very dangerous to your health."

A longer version - I'm really impressed with the data that are available about the risks of adverse outcomes for women after their first cesarean.  It is also shocking how much strong evidence there is about how dangerous the 2nd and 3rd and upward cesareans are.

Given what we know from these data, it seems clear that the lack of VBAC availability is not driven by concern for women's health outcomes.

A lot of the reasearch for this conference was compiled by OHSU's evidence-based practice center.  Go Oregon!

On with the webcast...

Pseudo-live Blogging - Cringe

I remember at the last NIH conference how hard it was for me to listen to my non-scientific birthing community colleagues rail at the deaf (or at least hard of hearing) ears of the researchers who had planned and were running the conference.  I'm cringing again while I watch the first participant comment opportunity.

It isn't that the researchers are bad guys (there that is again) it is just that they are dealing with the issues of VBAC in such a different way from the birthing community that they barely speak the same language, are barely talking about the same subject.

I wish there were more public health doulas & folks like my friend Judith (she was on the VBAC conference planning committee) who could advocate for women's rights in ways the researchers and scientists can understand.

Maybe after my kids go to college, I'll take that one on too.

Pseudo-live Blogging - VBAC conference

I've decided that during my kids' spring break I'm trying to watch the entire NIH Consensus Development Conference on VBACthat happened in Bethesda, MD March 8-10.  This conference is one of those important policy influencing events in which doctors, midwives, epidemiologists, lay birth professionals and consumers get togther and lay out personal experience, scientific research and policy decisions that influence important health outcomes.  Several years ago, while still living in Maryland I had the chance to attend a "State of the Science" conference put on by the same office.

What came after the conference, as came after this one, was a draft position statement that sounded rather benign and exploratory but was in fact quite controversial.  If I hadn't been in the room with the people directing the conference, it would have been hard for me to understand just how rigged the whole game had been.  So, I decided that even though I can read the draft statement for the VBAC conference quite easily, I would be missing something crucial not to watch as much of the actual event as possible.  Fortunately the whole thing is webcast and archived at the link above so if you were so inspired, you could watch too.

I am also finding the whole thing a thrilling challenge to my public health professional's brain - I am surprised at how much I am enjoying the talk about developing models to predict individual women's odds of VBAC success.  The whole thing is biostats and taking population-based knowns and translating them into something that will impact individually-based unknowns.

I have heard that there are many tear-jerking stories from women and providers about VBACs denied and I imagine it will evoke some of my own professional memory.  I have seen women bullied into primary cesareans, tricked out of VBACs and mis-managed all the way to the OR.  I don't have a good-guys V bad guys mentality, and I do honestly think that the nurses and doctors who's views on birth are so divergent from my own still have their patient's best interests at heart.  But I have seen flawed people act badly toward innocent women and even though I acknowledge that that doesn't make them bad guys, it is still hurtful to remember.