US obstetricians issue less restrictive VBAC guidelines, CIMS response

See below for an excerpt from the Wed 21st July release from the American College of Obstetricians and Gynecologists (ACOG):



Ob-Gyns Issue Less Restrictive VBAC Guidelines

For Release: July 21, 2010

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 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.

The Coalition for Improving Maternity Services (CIMS) is a US coalition of individuals and national organizations with concern for the care and wellbeing of mothers, babies, and families. Their mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. This is an excerpt from their response (click on link to read the entire release):


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."

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.