Thursday, August 26, 2010

ACNM Responds to ACOG’s 2010 VBAC Recommendations

On July 21, 2010, the American College of Obstetricians and Gynecologists (ACOG) released a revised practice bulletin on vaginal birth after previous cesarean section (VBAC). Today, ACNM released its response to the revised practice bulletin. Read on for an excerpt from the response, or read the full statement here [PDF].
ACNM’s philosophy is that all women—including those who have had a prior cesarean birth—should have access to information, counseling and birthing options provided by vigilant, skilled clinicians within a coordinated maternity care delivery system. While integrated resources should be made available in all settings, immediate access to emergency delivery solely to safeguard against the potential risks associated with TOLAC (trial of labor after cesarean) should not be the focus. Rather, risk associated with TOLAC should be considered within the spectrum of perinatal benefits and risks associated with nulliparous women in labor. Uterine rupture, a rare, often unpredictable complication of both trial of labor after cesarean as well as repeat elective cesarean delivery, is a primary factor underlying the ACOG recommendations. Yet the risk of uterine rupture associated with TOLAC is similar statistically to that of other obstetrical emergencies for a woman experiencing her first birth. Furthermore, it should be noted that the benefits of labor and vaginal birth are often omitted from this discussion. The focus is exclusively on risk, which does not yield a complete picture. Provided with the latest evidence and comprehensive counseling, women must be allowed to make decisions regarding TOLAC and give birth in the settings that best meet their individual needs. It is unclear how these fully informed women will be at liberty to choose a TOLAC when facilities continue to refuse them this option, claiming compliance with the 2010 ACOG guidelines.

ACOG’s 2010 practice guidelines may help to expand access to TOLAC for women with certain clinical presentations. However, ACOG’s continued recommendation that TOLAC be undertaken at facilities capable of immediate emergency deliveries virtually assures that the 2010 guidelines alone will fail to appreciably increase access to TOLAC and VBAC in the U.S. The NIH VBAC consensus statement recommends that “hospitals, maternity care providers, health care and professional liability insurers, consumers and policymakers collaborate on the development of integrated services that could mitigate or even eliminate current barriers to trial of labor” (p. 37). Only a long-term, system-wide, concerted effort based on quality evidence and further research in all settings will accomplish this goal. ACNM welcomes this important and necessary collaboration.
Read more [PDF]

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