CIMS Responds to Promising but Conflicting Revised VBAC Guidelines

CIMS Responds to Promising but Conflicting Revised VBAC Guidelines

Raleigh, NC (July 23, 2010)� The Coalition for Improving Maternity Services (CIMS) supports the recommendations of the March 2010 National Institutes of Health (NIH) Consensus Statement on VBAC (vaginal birth after cesarean) and is pleased by the American College of Obstetricians and Gynecologists' (ACOG) newly revised practice guidelines (Practice Bulletin #115) that encourage expanded access to VBAC and confirm a woman's right to labor after a prior cesarean. However, ACOG made limited changes to what the NIH concluded was a key factor that blocked access to VBAC -- ACOG's previous recommendation that VBAC should take place only in hospitals where physicians capable of performing an emergency cesarean, anesthesiology, and supporting staff are "immediately available."

CIMS questions why this restrictive recommendation is selectively applied to VBAC when the risks of potential complications associated with labor after cesarean (less than 1 percent) are comparable to any potential obstetric emergency, such as a cord prolapse that must be dealt with as promptly as possible in any setting. The NIH reported that this recommendation influenced about one-third of hospitals and one-half of physicians to no longer support VBACs.

CIMS welcomes ACOG's public re-admission of the safety of VBAC, a conclusion reached by an earlier NIH report published in 1980 as well as several ACOG guidelines issued before 1999, the year ACOG introduced the "immediately available" recommendation.

New guidelines state that VBAC is a safe and appropriate choice for most women with a prior cesarean and a low-horizontal uterine scar. Expanded criteria for women who can now plan a VBAC include women with two prior cesareans, women pregnant with twins, and women with an unknown uterine scar. Women with a prior low transverse uterine scar and who are otherwise at low risk with a breech baby should now have the option of an external cephalic version (ECV), a method of turning a breech head down after the 37th week of pregnancy.

CIMS believes each woman should give birth in an environment in which she feels nurtured and secure, and her emotional well-being, privacy, and personal preferences are respected. The new guidelines encourage physicians to review and discuss each woman's preference for VBAC and medical status on an individual basis. CIMS is pleased to find that women expected to give birth to a big baby (more than 8lb. 13oz), women past their 40th week of pregnancy, and women with a prior low vertical uterine scar should not automatically be scheduled for a repeat cesarean section. Currently more than 90 percent of women in the United States have a repeat cesarean surgery despite the fact that 60 to 80 percent of women who plan a VBAC go on to have a healthy vaginal birth. The national Healthy People 2010 goal for improving maternal and infant health had set a VBAC target of 37 percent.

"ACOG's emphasis on patient autonomy and the need for physicians to accurately discuss the benefits and risks of VBAC may open the door to informed discussions that can help women decide how they want to give birth," stated Michelle Kendell, MBA, AAHCC, chair of CIMS. "CIMS welcomes this long overdue change in thinking that will give more women greater access to VBAC."

The NIH reported that the "immediately available" recommendation, made by ACOG and the American Society of Anesthesiologists (ASA) in 2008, was based on opinion rather than strong support from high-quality evidence. More importantly, the NIH concluded that in too many areas of the country certain resources are "too few" for all hospitals to comply with the "immediately available" recommendation. CIMS questions the logic of drafting clinical guidelines that in fact cannot be realistically implemented.

NIH found that malpractice liability concerns in light of the continued "immediately available" recommendation may continue to restrain providers who would otherwise support women's wishes for VBAC.

CIMS gives ACOG much credit in its efforts to incorporate women's autonomy, values and preferences in their revised VBAC guidelines, but urges ACOG to reconsider and remove the current selective barrier to women's access to VBAC stemming from the "immediately available" recommendation.

Cesarean section is the most common major surgical procedure performed in the United States. CIMS is concerned about the dramatic increase and ongoing overuse of cesarean section. The surgical procedure poses short- and long-term health risks to mothers and infants, and a scarred uterus poses risks to all future pregnancies and deliveries. For these reasons, CIMS recommends that cesarean surgery be reserved for situations when potential benefits clearly outweigh potential harms.

The Coalition for Improving Maternity Services (CIMS) is a coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. Media inquiries: Denna Suko (919) 864-9482, [email protected]

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