Change in VBAC Guidelines

by Clive Riddle, July 22, 2010

The American College of Obstetricians and Gynecologists have just issued new guidelines for a vaginal birth after cesarean (VBAC).  Doctor Richard Waldman, president of The College tells us, "the current cesarean rate is undeniably high and absolutely concerns us as ob-gyns. 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."

Doctor Waldman adds, “Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC." The VBAC rate has dropped dramatically during the past 15 years, due to “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.”

What has changed? The College guidelines now state 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 trial of labor after cesarean (TOLAC).Proactive counseling is being emphasized, whereby “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.” They state that 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. 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. The new guidelines, Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is available in the August 2010 issue of Obstetrics & Gynecology.

Here’s three statistical items supplied by the College:

• U.S. Cesarean delivery rate: 5% in 1970; 31% in 2007.
• U.S. VBAC rate:  5% in 1985; 28% in 1996, 8.5% in  2006
• Risk of uterine rupture during a TOLAC: —between 0.5% and 0.9%