ACOG’s Revised Guidelines and Lack of Access for VBAC

In the August 2010 issue of Obstetrics & Gynecology the American College of Obstetrics and Gynecology (ACOG) published an update of its 1999 and 2004 clinical guidelines for VBAC. This follows the National Institutes of Health (NIH) Consensus Development Conference on VBAC (March 2010) findings of the latest research on the safety of VBAC. The revised ACOG guidelines (Practice Bulletin #115) reflect a much more positive view on the safety of VBACand make a strong statement in favor of women’s right to make informed decisions about how they want to give birth after a prior cesarean.

However, despite the NIH recommendation that ACOG reassess their statement that hospitals should have surgical and anesthesia personnel “immediately available” to perform an emergency cesarean when women labor for a VBAC, ACOG made no changes to this section of the guidelines. The NIH found that this requirement, not based on the available evidence, singled out women who plan a VBAC when in fact all women are at risk for unpredictable obstetric complications that require a rapid response.

By not making any changes in this recommendation, hospitals that cannot meet this requirement are not likely to begin offering medical care for VBAC. The NIH reported that the ACOG recommendation to have personnel “immediately available” as opposed to “readily available”, as recommended in all prior VBAC guidelines issued since the 1980s, has influenced about one-third of hospitals and one-half of physicians to no longer provide care for women who want a VBAC.

VBAC supporters will welcome the following statements from ACOG’s revised guidelines:

VBAC is associated with decreased maternal morbidity and a decreased risk of complications with future pregnancies and births. With a VBAC women can avoid complications of multiple repeat cesareans including infection, blood transfusions, bowel and bladder injury, and placental complications (placenta previa, accreta, and percreta).

  • The risk of uterine rupture with one prior low-transverse uterine scar is low, 0.5% to 0.9%.
  • About 60 to 80 percent of women who labor after a prior cesarean have a VBAC.
  • Most women with one prior cesarean with a low-transverse uterine scar should be counseled about VBAC and offered a trial of labor.
  • Women with a twin pregnancy, an anticipated big baby, with two prior cesareans, and women who do not go into labor at term can still plan a VBAC.
  • With a breech, women can choose to have an external cephalic version (ECV) after the 37th week, an effective procedure that may turn a breech into a head-down position.
  • Care providers should discuss the risks and benefits of VBAC and routine repeat cesarean with their patients early in pregnancy and document it in their medical record.
  • The ultimate decision to plan a VBAC or to have a routine repeat cesarean should be made by the patient in consultation with her provider.
  • Providers or hospitals who cannot or will not provide care for women who want to labor for a VBAC should refer women to VBAC supportive physicians and maternity centers.
  • Women can request an epidural for pain relief in labor.

Read the ACOG press release on the revised VBAC Guidelines:

Ob-Gyns Issue Less Restrictive VBAC Guidelines

Read responses to the VBAC Guidelines:

ACNM Responds to ACOG’s 2010 VBAC Guidelines

CIMS Responds to Promising but Conflicting Revised VBAC Guidelines

Lamaze’s Statement on ACOG’s New Clinical Management Guidelines on Vaginal Birth After Cesarean

Chilbirth Connection-Comparison of American College of Obstetricians and Gynecologists VBAC Practice Bulletin 115 (2010) with VBAC Practice Bulletin 54 (2004) and Induction of Labor for VBAC Committe Opinion 342 (2006) (PDF)

ICAN Responds to New ACOG Guidelines on VBAC
International Cesarean Awareness Network

A Victory for VBAC: ACOG revises its position
Choices in Childbirth

New Guidelines Seek to Reduce Repeat Caesareans
The New York Times

New C-section policy: Better for women?

ACOG Says Yes to VBACs
R H Reality Check

How will ACOG handle the PR challenge of promoting VBAC as a safe option?
The Unnecesarean

ACOG issues less restrictive VBAC guidelines

BREAKING NEWS: ACOG Admits What We Already Knew
The Feminist Breeder

Advocates Push ACOG to Remove Barriers to VBAC
R H Reality Check

Updated January 4, 2013.